Yes, this is all correct. I have recently completed an extensive review of
this subject for cancer that supports this. BUT, what Deaton found was that
the average health status of WHITE men as well as Black men is worse in
SMSAs with higher percent black population.
-----Original Message-----
From: Gar Lipow [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, August 28, 2001 11:47 AM
To: [EMAIL PROTECTED]
Subject: [PEN-L:16442] Re: RE: Re: Income Inequality and Health
I can suggest some stories.
One is aggressiveness of treatment. With very serious illness, there are
often broad choices within acceptable medical practice. A lot of the
judgments involved are explicitly social ones. For example, take two
people needing a transplant, same age, same basic health, same income,
same insurance -- one a member of the socially constructed group
"black", the other a member of the socially constructed group "white".
One factor in deciding who gets the priority is the medical judgment as
to who will follow post-operation instructions better. Who will take
their medicine as scheduled? Who will stick to the diet/rest/excercise
regimen prescribed? I don't have them in front of me; but I have seen
statistics that the doctors will overwhelmingly make the subjective
judgment that the "white" is more likely to comply.
Similarly, when allocating scarce memdical care (like transplants) an
important judgement is "who is most likely to die anyway". Given equal
income, equal objective measures of health, but different "races" -
guess who is judged the more hopeless case.
Note that this is in ADDITION to the pre-existing health, and income
dimensions. For example in transplants, normal insurance (if it covers
transplants at all) will get you on a single waiting list covering some
fraction the avaiable organs. If you are rich you can buy your way onto
all the lists (at a cost of about 10,000 per list) and thus have a much
better shot at receiving the transplant. But the above examples are for
people on the SAME list.
Umm - this is of course U.S. specific. Most industrialized systems don't
have quite as crazy a health care system.
"Brown, Martin - ARP (NCI)" wrote:
>
> I'll try to make the issues clear as mud...
>
> I was asking for opinions about the worth in this particular case, not
> asserting that they are not worth the effort. The most commonly noted
> weakness of ecological regressions has to do with measurement error. More
> example, say we are trying to establish a relationship between health
> status and income and we have individual data on stage-at-diagnosis for
> cancer (how early or late the cancer is diagnosed) and census tract level
> data on average income. There is measurement error in the latter as a
proxy
> for individual income. The most common criticism is that this result in
> lower power to detect a relationship when one actually exists, but some
> statistical purists say the bias can actually go in either direction. The
> discussion starts to get murky in the case of the Wilkinson hypothesis
> because this is a hypothesis that is inherently ecological, i.e., the
> relationship between some measure of average health status and some
measure
> on social structure. The problem is that this hypothesized ecological
> relationship is confounded by the fairly well established relationship
> between individual health status and individual income (or other measures
of
> individual social status). To deal with this problem Michael Wolfson
> simulates the expected effect of the individual level relationship on the
> ecological level and shows that there is still a residual effect at the
> ecological level that cannot be explained by the individual level
> relationship (this is for income/health, income distribution/average
health
> for U.S. SMSAs). Deaton, who have been very critical of the Wilkinson
> hypothesis accepts the Wolfson analysis but then says that percent black
> performs better in the ecological relationship than measures of income
> distribution. But I find percent black not to be nearly as conceptually
> compelling as income distribution as an ecological variable. E.g. what
kind
> of causal mechanism stories go with these measures???
>
> -----Original Message-----
> From: Bill Burgess [mailto:[EMAIL PROTECTED]]
> Sent: Monday, August 27, 2001 3:07 PM
> To: [EMAIL PROTECTED]
> Subject: [PEN-L:16413] Re: Income Inequality and Health
>
> Martin Brown wrote that ecological regressions (like average health
against
> average income plus income inequality) are not worth the effort. Could
you
> expand a bit on why? I think regession assumptions like linearity,
> independendence of variables and unidirection of causality are big
problems
> (on top of many issues regarding measuring health), but is this what you
> have in mind? If so, can you cite a non-econometric-technical summary of
> these problems, especially as they apply to health?
>
> Bill Burgess
>
> At 03:12 PM 24/08/01 -0400, you wrote:
> >I'll try to respond to this when I have more time to do it right. But
> there
> >is something else I wanted to bring up from the International Health
> >Economics Association meeting.
> >
> >There were several plenary and regular sessions focusing on the
"Wilkinson
> >Hypothesis". That is to say the theory that there is a relationship
> between
> >macroeconomic measures of income inequality and average health status.
> This
> >relationship is above and beyond that expected by the "Prescott Curve,"
> that
> >says there is a strong relationship between the level of individual
income
> >and individual health. To make a long story short, the consensus at the
> >meeting both from those who had been advocates and detractors of the W
> >hypothesis in the past is that current data and/or sophisticated analysis
> >does not support the hypothesis for most situations examined - e.g. OECD
> >countries, within UK, within Canada, within Australia. The remaining,
very
> >important case, is within the U.S. Some cross-sectional analyses of SMSA
> >data within the U.S. - notably by Michael Wolfson of Statistics Canada -
> >strongly support the hypothesis. The counter-argument, put forward by
> Angus
> >Deaton - an econometrician/development economist - is that when one
enters
> >percent black population into the regression for the U.S. the
coefficients
> >on the inequality measures drop out. This only happens if one looks
> >separately at health status (e.g. mortality) for blacks and whites
> >separately. And, note, white mortality is inversely related to percent
> >black population.
> >
> >There was some discussion to the effect that macro measures of social
> >structure still matter but that things like Gini coefficients of measured
> >income were never very good measures. Some discussion about dysfunction
> >urban structures in the U.S. being the real issue, etc....but apart from
> >this what should we make of this debate??
> >
> >1] All attempts a these kinds of ecological regression are not worth the
> >effort.
> >2] There is rationale for Deaton to substitute percent black for income
> >inequality.
> >3] Percent black is a proxy measure for something that really is
important
> >- but what is it??
> >
> >I will say this for health economics. 1] Would the questions of
inequality
> >ever dominate a meeting of AEA? 2] Would everybody at an AEA meeting,
> even
> >those on the political right end of the debate, concede the importance of
> >the Prescott curve, say that economists have ignored this for far too
long
> >and that we need to learn a lot more about the specific mechanisms behind
> >this statistical relationship and intervene with social programs to
address
> >it? 3] Acknowledge that the Prescott Curve, alone, tells us that total
> >social welfare would/should be improved by transfering social resources
> >toward lower end of the income distribution (because 99% of health
> >economists have pretty much accepted the proposition that a additional
unit
> >of health is/ought to be worth at least as much to a poor person as a
rich
> >person).
> >
> >On the down side, this debate has received the least visibility in the
one
> >country where the evidence suggests that both the Prescott Curve and
> >(perhaps) the Wilkinson effects are the strongest - the US.
