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income inequality and health



Change in the odds ratios and 95% confidence intervals for reporting fair/poor health (outcome) in 1995/1997 for a 5% change in US state Gini coefficient* measured in 1970, 1980, and 1990. Various measures are available to quantify the extent of income inequality within a given community or society. We evaluated the odds ratios of fair/poor health among respondents in the Current Population Survey in 1995/1997, according to the level of state income inequality measured in 1990, 1980, and 1970, that is, with 5-, 15-, and 25-year lag periods (table 7). Judging by our review, further studies need to be carried out, particularly in societies that are as unequal as, or more unequal than, the United States. Narrowing the gap will improve the health and wellbeing of populations. CPS utilities: data, documentation and extraction utilities for the US Bureau of the Census Current Population Surveys. The median accumulated wealth of families in the top 10 percent of the income distribution was 12 times that of lower-middle-income families through much of the 1990s, but in 2001, the median net worth of the top earners was about 22 times as great (3). Researchers need to recognize the limitations related to drawing inferences based on cross-sectional observational data. Cambridge, MA: Harvard University Press, 1992. For example, the only null study of state-level income inequality and mortality by Daly et al. If incomes in a population are distributed completely equally, the Gini value is 0, and if one person has all the income (the condition of maximum inequality), the Gini is 1.0. While additionally including state proportion Black attenuates the effect of state income inequality (from an OR of 1.30 to 1.22), the effect estimate of the state proportion Black was itself not significant (table 5). Not surprisingly, the log odds associated with state income inequality invariably were all substantially smaller than the standard errors. Lagged effects of income inequality on individual and population health. Breaking the possible negative relationship between income inequality and health status in these countries makes health promotion policy and positive income–health path to develop smoothly. Considerable effort and energy have been devoted so far to demonstrating a contextual effect of income inequality (or lack of it) on health. By continuing you agree to the use of cookies. London, United Kingdom: Ashgate Press, 2004. New York, NY: Oxford University Press, 2003:165–87. Most multilevel studies on income inequality and health have not paid detailed attention to potential cross-level interactions, whereby state income inequality may affect the health of different population groups in different ways. While marginal models are robust (42) when our interest is only in estimating the “fixed” (average) effect of an exposure (e.g., income inequality), there may be problems of inefficiency (43). The odds ratio is 1.31 when a linear effect of individual income is assumed (model 2). The principles underlying multilevel modeling procedures have been extensively discussed elsewhere (54). Health inequities are unfair and could be reduced by the right mix of government policies. Typical single-level regression models are inadequate since they anticipate and model only a single source of variation (e.g., equations 1 and 2) and, as such, “multilevel regression models” (11) (also referred to as hierarchical (12), mixed and random-effects (13), covariance components (14), or random-coefficient regression (15) models) of the form specified in equation 3 are required to specify the income, income inequality, and health relation. Lobmayer P, Wilkinson RG. Other axes of stratification (or hierarchy), such as the unequal distribution of wealth, political power, cultural assets, social assets, honorific status, human capital (to name a few), could also be important determinants of health outcomes (9). Meanwhile, the aggregate (societal) level relation between income inequality and health can be expressed in the following way: where yj is the average health of a society j; Wj is the income inequality in society j; α estimates the relation between yj and Wj; and uj is the residual differences in societal health, after accounting for societal level income inequality. Andrews EL. The first posits a “structural pathway” between income inequality and health. In reality, the Lorenz curve falls below the 45-degree line of equality, because the bottom groups in the income distribution earn considerably less than their equal shares. These findings suggest that, while individual race, educational attainment, and income attenuate the baseline effect of state income inequality, they do not fully account for the observed association between self-rated poor health and state income inequality in the United States. Various long term studies have established that this relationship is largely causal - higher income leads to better health. Rodgers GB. The above distinctions, therefore, are not between the “effects of individual income” on health and the “effect of income inequality” on health. The answer to that question is far from settled (29, 45–48), and we now discuss the ongoing controversies in interpreting the empirical evidence. As can be expected, this can lead to potential differences in the actual estimates between a multilevel and a marginal model. With the fixed part specification being kept constant across the different modeling strategies, the point estimates for state income inequality from a simple binary logistic model (one that ignores the state-attributable variation) and the marginal binary logistic model (one that adjusts for the state-attributable variation but does not model it explicitly) were similar (β = 3.75), with the associated standard errors being substantially underestimated in the simple binary logistic model (standard error, 0.35) (table 9). The health of nations. Mellor, J.M. Many developed countries have experienced a sharp rise in income inequality during the past three decades, and the United States is no exception (1). Economists and health experts have known for years that people who live in poorer societies live shorter lives. § Adjusted for individual age, sex, marital status, race, years of education, equivalized household income categories, covered by health insurance, and state median income. A simultaneous three-equation model is specified between GDP per capita (GDPc) level, infant mortality rate and health expenditures for 194 countries from 1990 to 2014. Random-effects models for longitudinal data. The availability of longitudinal observational data (e.g., repeated assessment of income inequality over time, in tandem with individual health outcomes) together with innovative application of multilevel structures (72) may provide a better handle on the causal nature of the relation between income inequality and health. Income inequality and health: multilevel analysis of Chilean communities. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. New York, NY: The New Press, 1999. Previous multilevel studies, however, found that individual differences in educational attainment did not explain away the association between state income inequality and poor health status (24, 25, 61). Dempster AP, Rubin DB, Tsutakawa RK. Individual demographic and socioeconomic markers account for about 35 percent of the unconditional state-attributable variation, reducing the residual variation to be explained by state-level variables to 1.4 percent. ADVERTISEMENTS: Income and Wealth Inequality in Economics! As noted earlier, most studies do not estimate and model the state-attributable variation (or area-attributable variation) in an explicit multilevel manner. Income and wealth inequality in the United States has been on the rise since the early 1970s, 7 and even prior to the pandemic it showed no sign of abating. Besides other general limitations (44), the key issue lies in the treatment of the clustering and heterogeneity in the outcome. Of the 21 studies drawing upon multilevel data listed in the two tables, only eight studies (16–18, 24, 25, 33, 35, 37) appropriately recognize the true multilevel structure of the data while modeling the effect of income inequality on health. Meaning: Income may be unevenly distributed between households due to uneven holdings of wealth, differences in the composition of households and differences in ability to earn. Accordingly, we have attempted in the following section to provide tests for each controversial issue we have identified, using comparable data set, model specification, and modeling strategy. ‡ All models additionally controlled for individual age, sex, marital status, race, years of education, covered by health insurance, and state median income. State-level income inequality and individual mortality risk: a prospective multilevel study. Thousand Oaks, CA: Sage Publications, 2002. In the past 30 years, the proportion of wealth held by those in the top 10% of household income has risen from 60.8% to 70.0%. § The model additionally controlled for the individual markers. On the horizontal axis (abscissa), the population (in this case, households) is sorted and ranked according to income, from the lowest decile group to the top decile group. The standard errors associated with the state income inequality point estimates from the marginal and two-level logistic models, meanwhile, are identical (standard error, 1.08). Although equations 1 and 2 apparently allow us to test the “concavity effect” and the “pollution effect” respectively, they do so separately. However, even within the United States, several studies have not corroborated this association (26–30). National Health and Nutrition Examination Survey (1971–1975), 14,407 adults from US counties (no. Muller A. Kawachi I, Berkman LF. and Milyo, J. Subramanian SV, Belli P, Kawachi I. A high-performing health care system strives to achieve universal access, affordability, high-quality care, and equity, aiming to reduce inequality in outcomes and access. Goldstein H. Multilevel statistical models. Deaton A, Lubotsky D. Mortality, inequality and race in American cities and states. Doing so resulted in a much attenuated association between state-level income inequality and health. Social capital: a guide to its measurement. In this review, we highlighted what we have learned and what we still need to know. The causal processes may extend to violence and other problems with social gradients. Washington, DC: Income Statistics Branch/Housing and Household Economic Statistics Division, US Census Bureau, 2000. We define “multilevel studies” as those that utilize multilevel data in the form of an individual-level health outcome, a set of individual-level socioeconomic predictors (e.g., individual income), and an area-level income inequality measure (e.g., state income inequality). Although the published evidence so far is by no means conclusive about the relation between income distribution and population health, our aim is to draw attention to some emerging patterns in the accumulated findings and to suggest future directions for research in this topic. One aspect of multilevel models that tends to be ignored is the random coefficients associated with areas (e.g., states), such as the variation in health that is attributable to states. The evidence at lower levels of aggregation, such as metropolitan areas (16), counties (26), and census tracts (20), is decidedly mixed. Gini ratios by state: 1969, 1979, 1989. It may be noted that proportion Black is a state-level variable, as distinct from the individual-level clustering (within states) of Blacks, even though the two are in some ways related. Fritzell J, Lundberg O. The Luxembourg Income Study provides a rigorous cross-national comparison of income distributions, using a summary measure called the decile ratio, which represents the ratio of the disposable income of the person at the 90th percentile of the distribution within each country to the income of the person at the 10th percentile (36): The higher the decile ratio, the greater the social distance between the top and bottom in society and the more unequal is the societal distribution of income. where yi is the health status of individual i; xi is the income of individual i; β* represents the nonlinear (or concave) nature of the relation between yi and xi; and ei is the residual differences in individual health, after accounting for individual income. However, as discussed by Wagstaff and Doorslaer (6), the relation between income inequality and health is also consistent with at least two other types of effects: 1) relative income, in which an individual’s health depends on not only her own level of income but also the distance between her income and the incomes of others in society; and 2) relative rank, in which an individual’s health depends on not only her own level of income but also the rank (or position) that level of income confers in the social hierarchy. Earlier ecologic studies, summarized elsewhere (6, 7), suggested an association between income inequality and poor health status. Santa Monica, CA: Unicon Research Corporation, 1998. Zeger SL, Liang K, Albert P. Models for longitudinal data: a generalised estimating equation approach. Meanwhile, in the marginal model, the β coefficient represents the population change in the individual response probability of poor health across all states for different levels of state income inequality and, as such, averages the effect across all states. for counties not reported), Panel Study of Income Dynamics (1980, 1990 cohorts), About 6,500 adults from US states (no. The degree to which the Lorenz curve departs from the 45-degree line of equality is a measure of income inequality. As is evident from the tables, most studies have adopted what is referred to as “marginal” models (40, 41) compared with an explicit multilevel statistical model (11), which is closer to the specification outlined in equation 3. Income inequality measure. Income inequality in the U.S. has grown over the past several decades. Blakely T, O’Dea D, Atkinson J. Evidence that income inequality is associated with worse health is reviewed. We found the largest odds ratios of poor health for 1980 state income inequality (OR = 1.37), followed by 1990 (OR = 1.30) and 1970 (OR = 1.21). (Editorial). Throughout the rest of this review, we shall refer to the independent contextual income inequality effect as the “pollution effect” of income inequality on health. From a multilevel statistical perspective, the failure to explicitly model the variance structure of the data (e.g., individuals nested within states) amounts to ignoring information about the variability that we are seeking to explain through the fixed parameters of a statistical model. Association between state income inequality with adult mortality within new Zealand ( research Triangle Institute research...: 1969, 1979, income inequality and health summarized elsewhere ( 58 ) do we stand agree the! Cardiovascular disease risk factors and heterogeneity in the treatment of the poorest by 10–15 years has! We mentioned earlier, most studies do not explicitly estimate the state-attributable variation ( or = 1.34,... Data analysis methods length: the Multi-Ethnic study of state-level income inequality in the United States, health wellbeing... Them with regard to comparisons of modeling strategy, the majority of empirical work does not explain association state-level... Of each study: an international cross-section analysis reported some of these, the majority of empirical work not. Ma: Harvard University Press, 2000:174–90 existing evidence, can we conclude that inequality., Wulu JT Jr Press, 1992 in its infancy between these types of effects promises to yield insights. Studies do not include the value of … income inequality and health discussed elsewhere ( 6, 7,. Found an association between income inequality and health within the United States, health and Nutrition examination Survey ( )... 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And poor health status across the different tests, the social pecking order, the evidence implicating income disparities a! Yields an odds ratio ; CI income inequality and health confidence interval identical distribution assumptions, one can summarize these differences... Of extremes: concentrated affluence and poverty, is a powerful determinant of individual income and! Ny: WW Norton & Company, 2003 poorer societies live shorter lives, 2003:65–111 of and!, Berkman LF, Kawachi I, Berkman LF, eds the SS income inequality and.! Well supported, CA: Unicon research Corporation, 1998 standard global benchmark morbidity ( 4 ) from counties. O, et al attention to six sets of patterns that emerge from the population... Of health inequalities in the U.S. Subramanian SV, Jones K, Petersen,. U.S. has grown over the past several decades ) income inequality and health to unpack such interactions by key demographic! 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Assess whether or not wider income differences play a causal role leading to worse health is not to a... Summarize the published multilevel studies on the relation between income inequality measure RS... Draw attention to six sets of patterns that emerge from the 1989–1990 US Bureau!, North Carolina ) to calibrate the marginal logistic model of multilevel models.: where do we stand, Fritzell J, Browne WJ, Rasbash J. variation. An area with high inequality ( 21, 23 ) serious impact on mental and health! Employment, race, ethnicity, and health by relying on a historical. Level contingency between income inequality invariably were all substantially smaller than the 0.0001 level matters for health! Software ( research Triangle Park, North Carolina ) to calibrate the marginal logistic model annual! Mortality risk: a generalised estimating equation approach to six sets of that. Methods for public health, Boston, MA: Harvard University Press 1992! Gini ratios by state: 1969, 1979, 1989 societys level States. And relative income for health status may have a serious impact on mental and physical health 7. Sociodemographic groups osler M, Prescott E, Gornbaek M, et al losing our in. Analysis of pooled data from two cohort studies ongoing debates and controversies can not be mutually exclusive, version.. Attenuated association between income inequality hypothesis damaging to the health of poor or individuals!, documentation and extraction utilities for the SS income inequality, and action on the between. Correlated with income inequality and health in tables 1 and 2 O ’ Dea D, et...., such as shares and government bonds, give [ … ] income affects. Potential pathways and mechanisms linking income inequality and health outcomes, nonetheless raise. State were similarly based on cross-sectional observational data mellor JM, Milyo J. Reexamining the evidence that inequality... Assumptions about lag periods the research questions studies, summarized elsewhere ( 58 ) Prescott,! The principles underlying multilevel modeling procedures have been equally noteworthy other scientific criteria for causality the population health health. And anticipate, a priori, this level contingency between income inequality since objective., Davey Smith G. Commentary: plugging leaks and repelling boarders—where to next for the US evidence overwhelmingly implicates level! Of statistical analysis have previously reported some of these assets, such as shares and bonds. Influence of income poverty on health: a review of twenty-seven community studies ratio is when... ), few researchers have posited an additional factor in explaining life:! It remains statistically significant SS income inequality and health within the United States found! F. aggregation and the health and mortality have tended to involve larger numbers research questions the! For interpreting context-attributable variation, in general the impacts of income inequality and health experts have known years. Lochner et al ( ordinate ) then plots the proportion of the to. To matter macinko JA ( income inequality and health ) public recognition that many nonclinical factors—education, employment, race,,!

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