《健康經(jīng)濟(jì)學(xué)》課件Chapter4

IntroPreviously…GrossmanmodelIndividualsmakechoicesabouttheirhealthbasedontimeconstraints,budgetconstraints,andutilityOptimalamountofhealth(H*)changesbasedondecisionsabouttradeoffsHowdoessocioeconomicstatus(SES)affecthealthandchoicesabouthealth?DoeshealthdetermineSES?OrdoesSESdeterminehealth?UseempiricalevidencetoexplorethesequestionsThepervasivenessofhealthdisparitiesHealthdisparitiesareeverywhereHealthDisparity:(def)differencesinhealth--incidence,prevalence,mortality,andburdenofdisease--betweenspecificpopulationsex:deathratesforallcancertypesforbothmenandwomenarehighestamongAfricanAmericans1Ubiquitousworldwideacrossraces,educationalattainments,employmentgrades,andincomesBroadlyacrossallsocioeconomicstatuses(SES)HealthdisparitiesareeverywhereByeducation:Collegegraduatesare25%morelikelytosurvivetoage68thanhighschooldropoutsByrace:HispanicsreportbetterhealthstatusthanblackindividualsWhiteindividualsreportbetterhealththenbothHispanicandblackindividualsHealthdeteriorateswithageacrossallraces,butdisparitiespersistHealthdisparitiesacrossincomeGenerally:high-incomeindividualsself-reportahigherhealthstatusthanthoseoflowerincomesFormostconditions,thepoorexhibitmoreincidencesofdiseaseSomeexceptionslikeBronchitis--nodifferenceHayfever--therichappeartobediagnosedwithhayfevermoreoftenMaybeexplainableifricherchildrenvisitthedoctormoreoftenandhence,aremorelikelytobediagnosedDisparitiesevenwithuniversalinsuranceEvenincountrieswithuniversalhealthinsurance,healthdisparitiespersistCanada:Self-reportedhealthstatusforchildrenathighSESbetterthanchildrenoflowSES(CurrieandStabile2003)England:WediscusstheWhitehallstudieslaterTheoriestoexplainhealthdisparitiesWhydohealthdisparitiesexist?Reasons/theoriesEarlylifeeventsIncomelevelsStressofbeingpoorWorkcapacityImpatienceAdherencetomedicaladvicePolicyimportanceofunderstandingcausesofdisparitiesbeforeaddressingthemWhatcauseswhat?DoesbadhealthcauselowSES?DoeslowSEScausebadhealth?Arethereotherfactors?HypothesesforhealthdisparitiesEfficientproducerThriftyphenotypeDirectincomeAllostaticloadIncomeinequalityAccesstocareProductivetimeTimepreference(TheFuchshypothesis)TheGrossmanmodelandhealthdisparitiesRecallMECindicatesthereturnoneachadditionalunitofhealthcapitalDifferentSESgroupsmayhavedifferentMECsWhy?EachhypothesispositsadifferentreasonTheefficientproducerhypothesisHypothesis:better-educatedindividualsaremoreefficientproducersofhealththanlesswell-educatedindividualsGrossmanpredictsthatpeoplewhoaremoreefficienthealthproducerswillhavehigherH*Lleras-Muney(2005)findthatanadditionalyearofschoolingcaused~1.7yearincreaseinlifeexpectancyin1920sUSHence,educationimproveshealthTheefficientproducerhypothesisPossiblecausalmechanismsPossiblereasonsforpositivecorrelationbetweenhealthandeducation?LessonsinschoolhelpstudentstotakebettercareofthemselvesSchoolinghelpsstudentsbemorepatientwhenitcomestopayoffsofinvestments(likehealth)Better-educatedmorelikelytoadheretotreatmentregimensTheefficientproducerhypothesisThriftyphenotypehypothesisGeneticreasonsforbeinginefficientatproducinghealthDeprivationofresources(food)inuteroandearlychildhoodleadstoactivationof“thrifty”genesthatareusefulforsparseenvironmentalconditionsThese“thrifty”genesgoodforscarceenvironmentsbutbadinconditionsofabundanceMorelikelytodevelopdiabetes,obesity,andotherdisorderslaterinlifeDisparitiesarisebecausepoorerindividualsaremorelikelytohaveresourcedeprivationearlyinlifeThethriftyphenotypehypothesisThriftyphenotypehypothesisUsenaturalexperimentstotestthishypothesisArandomizedexperimentthatrandomlydeprivedsomechildreninuteroandnototherswouldbeprettyunethical!NaturalexperimentsuseenvironmentalshocksthatnaturallycreatecontrolandtreatmentgroupsEx:earthquakes,famine,snowstormsGoodnaturalexperimenteliminatesselectionbiasThethriftyphenotypehypothesisTheDutchfaminestudyNaturalexperiment:DutchfamineinWWII(Rosebloometal.2001)HollandsufferedafamineduetoaGermanblockadeoffoodCreatedtwobabygroups:ThoseinuteroduringfamineThoseconceivedafterfamineTwogroupsaresimilar,exceptforinuterodeprivationSohopefullynoselectionbias!Findings:BabiesinuteroduringfaminehadhigherratesofdiabetesandobesityinadulthoodThethriftyphenotypehypothesisThedirectincomehypothesisHypothesis:disparitiesexistbecauserichpeoplehavemoreresourcestodevotetohealthRichindividualshaveanexpandedPPFbecauseofextrafinancialresourcesExpandedPPF=higherH*thatcanbeobtainedThedirectincomehypothesisAllostaticloadhypothesisHypothesis:ProlongedorrepeatedstressisunhealthyandcancauseanincreasedrateofagingIntheGrossmanmodel,agingisrepresentedbyrateofdepreciationofhealthcapitalδHighstressloadleadstoahigherδTheallostaticloadhypothesisTheWhitehallstudyWhitehallstudybyMarmotatal.(1978,1991)CompareshealthstatusofBritishcivilservantsBritishcivilservantsrelativelyhomogenousinbackgroundandshareworkplaceenvironmentsAllBritishcitizenshavethesameaccesstohealthcarethroughtheNationalHealthService

Findings:Diseasemorbidityandmortalityrateshighestforlow-gradecivilservantsLow-gradecivilservantsreportedmorestressfulworkandhomeenvironmentsTheAllostaticLoadHypothesisIncomeinequalityhypothesisHypothesis:HealthdisparitiesarecausedbyanunequaldistributionofincomeRelatedtotheallostaticloadhypothesisMoreequalsocietiesarelessstressfulandthereforehealthierPolicyimplications?IftheoryistruethenpolicymakersshouldaimatreducinginequalitywithinacommunityThehealthstatusofasocietymaydeclineevenifaverageincomerisesifincomebecomesmoreconcentratedTheDirectIncomeHypothesisAccesstocarehypothesisHypothesis:ThosewithhighincomescanaffordmoregeneroushealthinsurancecomparedtothoseoflowincomeButhealthdisparitiespersistincountrieswithuniversalhealthinsuranceCanadianyouth(CurrieandStabile2003)Britishcivilservants(Marmotetal.1978,1991)bothcountrieshaveequalaccesstohealthcare!TheaccesstocarehypothesisProductivetimehypothesisSESdifferencesarecausedbydisparitiesinhealth

BadhealthleadstolowerproductivetimeandthereforelesstimetoproduceincomeOreopoulosetal.(2008)andBlacketal.(2007)studysiblingsgrowingupinsamehousehold

Thosewithworsehealthduringinfancyhavehighermortalityrates,lowereducationalachievement,andloweradultearningsTheproductivetimehypothesisTheFuchshypothesisBadhealthdoesnotcauselowS