The roots of health inequality and the worthiness of intra-family expertise
Yiqun Chen, Petra Persson, Maria Polyakova
Poorer folks have worse health at birth, are sicker in adulthood, and die younger than richer people. Aside from socioeconomic status, contact with informal health expertise could also affect health. Using data from Sweden, this column examines whether having a doctor in the family impacts health. It concludes that differences in contact with informal health expertise can take into account a number of the observed patterns of health inequality, even within an environment with universal medical health insurance and equal formal usage of healthcare.
Poorer folks have worse health at birth, are sicker in adulthood, and die younger than richer people. Indeed, growing evidence across various disciplines reveals stark correlations between health capital and socioeconomic status (e.g. Marmot et al. 1991, Case et al. 2002, Deaton 2002, Currie 2009, Lleras-Muney 2018).
Yet, the mechanisms underlying these associations are poorly understood. Several proposed explanations claim that individuals growing up in poor households make fewer investments to their health throughout their lifetime, albeit we have no idea why this is the case.
In a recently available paper, we ask whether unequal usage of informal health expertise plays a part in health inequality (Chen et al. 2019). The overwhelming share of individuals’ decisions about their own health investments happens beyond the walls of the formal healthcare system. If, from an extremely young age, children in poorer households face less health-related expertise, and, consequently, acquire less tacit understanding of how to spend money on their health, then we’d expect these children to have worse health insurance and higher mortality as adults.
Thus, our hypothesis is that contact with informal health expertise affects health, and, consequently, that unequal usage of such expertise may perpetuate differences in health between richer and poorer households. To check this hypothesis empirically, we consider one quantifiable way of measuring contact with informal health expertise: having a doctor – a physician or a nurse – in the family.
For our analysis, we use rich administrative data from Sweden. These data include rich socioeconomic information, precise information regarding education, detailed birth records, healthcare records, and prescription drug records, and mappings of family trees spanning four generations.
Despite Sweden’s universal medical health insurance system and generous social back-up, we document pronounced inequality in mortality and morbidity. For instance, out of 100 people that are alive at age 55, nearly 45 could have died by age 80 in the bottom of the income distribution (lowest 5%), while less than 25 could have died among the very best 5%. We find similarly large differences in the prevalence of lifestyle-related chronic conditions at older ages, in the rate of preventive investments among adolescents, and in the rate of prenatal tobacco exposure. Hence, despite equalised formal usage of healthcare and a well-developed social back-up, Sweden exhibits substantial health inequality, measured across an array of ages and conditions. Actually, we find that at age 75, mortality inequality is equally pronounced in Sweden since it is in america.
These facts motivated us to examine a mechanism apart from differences in medical health insurance or usage of care that may perpetuate socioeconomic differences in health. Specifically, we ask whether an eternity of differences in contact with informal health expertise can take into account a number of the observed patterns of health inequality. Differences in the tacit understanding of how to spend money on one’s health, it appears, could persist even within an environment with universal medical health insurance and equal formal usage of healthcare.
We begin by comparing individuals who’ve a health care provider or a nurse in the family to observationally similar individuals who usually do not. We find that folks with relatives in medical profession are 10% much more likely to live beyond age 80. Also, they are significantly less more likely to have chronic lifestyle-related conditions, such as for example heart attacks, heart failure, and diabetes. Younger relatives within medical professional’s extended family also see gains: they will get vaccinated, have fewer hospital admissions, and also have less prevalence of drug or alcohol addiction. Furthermore, the closer the relatives are with their familial medical source-either geographically or within the family tree-the more pronounced will be the health benefits, according to your findings.
Naturally, we might get worried that families with a nurse or a health care provider are simply not the same as other families in a few ways we can not observe. These families may talk more about health, may have healthier habits, and could make larger preventive health investments, for instance. In a nutshell, they could both be healthier and also have a doctor in the family because of the interest in health-rather compared to the other way around.
To overcome this also to quantify the role of informal contact with health expertise with a medical expert in the family, while avoiding results that might be muddled with other differences between people with and with out a doctor in the family, we use two different empirical approaches.
First, we make use of the fact that in a few years and for a few sets of applicants, randomisation was used to break ties among equally qualified applicants to Sweden’s medical schools. This enables us to use medical school application records and compare the fitness of family of applicants who won and lost such ‘lotteries’ (applicants can reapply, so we utilize the lottery outcome on an applicant’s first admission attempt). We find that having a member of family matriculate into medicine reduces older individuals’ threat of heart attack and cardiovascular disease, raises preventive investments and adherence to cardiovascular medication, and generally improves health. Each one of these effects are measured over an interval of six to eight 8 years from the relative’s matriculation into medical school. Younger generations also reap the benefits of having a member of family get medical training: they make larger preventive investments, will get vaccinated, and also have fewer hospital admissions and addiction cases.
Second, we examine long-run outcomes by comparing mortality and the prevalence of chronic conditions in the extended groups of individuals who train as physicians and lawyers, respectively. While both professions enjoy similar degrees of income and social status, doctors have an increased amount of health expertise they can transmit with their families. Comparing a lot more than 30 years of detailed health records, we find that family of doctors are 10% much more likely to be alive than members of the family of lawyers 25 years after their younger relative matriculated in medical or law studies (see Figure 1). The relatives of doctors also faced lower prospects of lifestyle-related chronic diseases.
Figure 1 Doctor in the family and long-run mortality: Event study
Notes: The figure illustrates the impact of experiencing a member of family trained as your physician (in accordance with having a member of family trained as an attorney) on the likelihood of death, along with 95% confidence intervals. The regressions are centred at event year -1, i.e. 12 months prior to the year of matriculation in a medical (or legal) degree. The dashed vertical line marks the common graduation time for physicians. Standard errors are clustered at the family level. The estimates reveal a clear slowdown in the relative mortality rate among relatives of doctors (when compared with the relatives of lawyers) that starts emerging around year 8 following the young relative matriculates into college. The mortality gap then steadily widens for just two decades. The idea estimates suggest a 1.7-percentage-point reduction in the likelihood of death by event time 25, which corresponds to a 10% decline off the mean among relatives of lawyers, which is 17%. The sample includes family born in Sweden between 19. We exclude family who are themselves a doctor or have a doctor spouse.
An explanation that’s commonly discussed in policy circles for the existence and persistence of a poor correlation between socioeconomic status and health is differences in usage of healthcare over the socioeconomic spectrum. Our evidence shows that this explanation can only just be one little bit of medical inequality puzzle. What’s more, our results imply a scarcity of usage of expertise in households at the low rungs of the socioeconomic ladder can create and sustain inequality in health outcomes-even within an environment with fully equalised usage of formal healthcare, generous social insurance programs, and a broad social back-up.
It really is encouraging, however, that the huge benefits accruing to medical professionals’ members of the family seem to be scalable. Our analysis shows that usage of expertise improves health not through preferential treatment, but instead through intra-family transmission of ‘low-tech’ (and therefore, cheap) determinants of health, likely which range from the sharing of nuanced understanding of healthy behaviours to reminders about adherence to chronic medication, also to frequent and trustful communication about existing health. Therefore that public health policies, together with carefully designed public and private medical health insurance contracts that successfully mimic intra-family transmission of health-related expertise, could have the potential to close a substantial share-our estimates suggest around 18%-of the income-mortality gap.
Case, A, D Lubotsky and C Paxson (2002), “Economic status and health in childhood: The origins of the gradient”, American Economic Review 92(5): 1308-1334.
Chen, Y, P Persson and M Polyakova (2019), “The roots of health inequality and the worthiness of intra-family expertise”, CEPR Discussion Paper 13583.
Currie, J (2009), “Healthy, wealthy, and wise: Socioeconomic status, illness in childhood, and human capital development”, Journal of Economic Literature 47(1): 87-122.
Deaton, A (2002), “Policy implications of the gradient of health insurance and wealth”, Health Affairs 21(2): 13-30.
Lleras-Muney, A (2018), “Mind the gap: An assessment of medical gap: The task of an unequal world by Sir Michael Marmot”, Journal of Economic Literature 56(3): 1080-1101.
Marmot, M G, S Stansfeld, C Patel, F North, J Head, I White, E Brunner, A Feeney and G Davey Smith (1991), “Health inequalities among British civil servants: The Whitehall II study”, The Lancet 337(8754): 1387-1393.