A recent article by Benjamin Ho and Sita Nataraj Slavov, which I picked up via Marginal Revolution, argues that health inequality is falling. The argument is that life expectancy for the 1% dying at the bottom end of the age-at-death distribution has increased by more than the life expectancy for the 1% at the top. I’m struggling to think of much academic work being done to look at levels of health inequality in this way. However, I’m not sure what answering such questions could add.
Plenty of work has been done on how to measure health inequality. It seems a pretty heinous crime to talk about health equality without mentioning Culyer and Wagstaff. More recently, new models of health inequality have been developed that bare varying levels of equivalence to a standard concentration curve (see here, here, here, here etc). But the authors of the aforementioned article are really interested in pure health inequality, irrelevant of income or socio-economic indicators. Some work has been done here too (see here, here, here etc); indeed, the age-at-death distribution thing was done by Le Grand.
Pure health inequality
Health and income are very different in a number of ways, and it seems a misnomer to compare income inequality with health inequality. The most important difference, probably, is how society views the two. Society has some aversion to income inequality and also aversion to health inequality. However, we don’t just prefer a more equal distribution of health; we want equal full health (i.e. health maximisation). Assuming diminishing marginal returns to health care (in terms of health), we will tend to prioritise those in worse health and tend towards equality. I would argue that health can only increase indefinitely in terms of longevity. We may live longer and longer but I think ‘full health’ is a very real ceiling while we’re alive. It simply isn’t possible for a super-rich elite to develop in terms of health. What would these people be like? Bionic presumably, but that’s a different debate. Even if health could be amassed indefinitely it wouldn’t be, as health has no value in exchange.
For me (given society’s aversion to inequality, technological progress and a maximum level of health at any point in time), movement towards equal health seems inevitable. You don’t need to agree with the Grossman model to accept that health represents a kind of ‘stock’. It therefore bares more resemblance to wealth than to income. Health requires some effort to maintain, but not to the same degree as income. Ho and Slavov’s article also introduces the idea of a lottery; luck plays an important role here. Society reacts differently to an income shock (say, unemployment) than it does to a health shock (say, being hit by a car). As with income there might be fair and unfair inequalities, but either way society is going to attach more weight to reimbursing an individual’s loss of health than an individual’s loss of income (unless, maybe, the latter is a result of the former). The same applies to those dealt a nasty hand at birth. In countries where health care is dependent on ability to pay there will certainly be more of a link between health and income; and thus between health inequality and income inequality. In countries like the UK, income inequality seems less likely to affect health inequality.
Health is becoming more equal; I won’t disagree with that. But, for the reasons outlined above, this seems somewhat inevitable. I suppose that doesn’t mean we shouldn’t celebrate it, but it does raise into question the value of doing so when there are real discrepancies between different demographics’ health that need addressing.
Cynics may spot the benefit of such an approach for those at the top of the income distribution…