INEQUALITIES IN HEALTH AND HEALTHCARE

Transcription

1 INTERNATIONAL DOCTORAL COURSES IN HEALTH ECONOMICS & POLICY SWISS SCHOOL OF PUBLIC HEALTH + INEQUALITIES IN HEALTH AND HEALTHCARE UNIVERSITY OF LAUSANNE JUNE 2017 OVERVIEW: Health differs markedly by education, race, occupation and income. In high-income countries, a 30-year-old male college graduate can expect to live almost eight years longer than a contemporary with only compulsory schooling. The striking magnitude and the persistence of socioeconomic disparities in health is a major public health issue. In the context of population ageing and rising medical expenditures, it is also attracting attention in economics. This course will arm you with tools to measure health inequality. In addition to gaining competence in the computation of health inequality indices, you will be forced to consider the normative implications of the measures. You will also become familiar with the theoretical and empirical literature in economics that seeks to explain socioeconomic disparities in health. And you will be exposed to epidemiological approaches to understanding these inequalities. Finally, you will be introduced to the analysis of equity in the distribution of healthcare. The course is targeted at economists embarking on research on population health, as well as at researchers from the field of public health wishing to become competent in techniques used by economists to analyse inequality in health and healthcare. OBJECTIVES: To attain competence in: normative evaluation of health inequality; measurement of health inequality; computation of health inequality indices; decomposition of health inequality; To become familiar with: epidemiological approaches to health inequality; economic models of health behaviour; analysis of equity in the delivery of healthcare; LECTURERS: GUEST LECTURER: Owen O Donnell and Tom Van Ourti, Erasmus University Rotterdam. Silvia Stringhini, IUMSP, Lausanne University Hospital LOCATION: EXTRANEF ROOM 125 PREREQUISITES: This course is open to research master students, PhD students, Postdocs and researchers with an interest in a quantitative approach to health inequality. Students should have done an intermediate course in statistics, be familiar with regression analysis and preferably have completed an intermediate course in microeconomics. Those with a public health background who have not previously followed a course in economics should be comfortable with statistical analysis. Familiarity with the statistical package STATA is an advantage. 1

2 FORMAT: Lectures introduce concepts, explain measures and models, and review evidence. Practical computing sessions using Stata provide hands-on experience with the computation of measures, application of decomposition techniques and estimation of causal effects. Example Stata do files are provided. Seminars provide an opportunity to embed understanding through discussion. CREDITS: 3 ECTS ASSESSMENT: 3 ECTS will be awarded conditional on submission of a written assignment by July 24, 2017 that is given a PASS, plus oral presentation of the assignment on June 30, The assignment consists of an empirical exercise on measurement and explanation of health inequality. Specific questions are posed that require generation and interpretation of results. Datasets are made available but students are encouraged to use their own data. Assessment is based on both the oral presentation and the written report. A document that describes the content of the assignment will be distributed. COURSE MATERIAL: Lecture slides, assignments, Stata do, ado and data files, and some book chapters referenced are available from the Dropbox folder IHHC. Hardcopy of lecture slides are distributed. Suggested reading related to the content of each session is provided below. You are NOT expected to read all of these references. They are provided to make citation in lectures easier and to identify key references on a topic that the interested student may want to follow up. You are expected to have your own laptop capable of running Stata. If you do not have Stata installed on your laptop, please inform the course administration on application. MONDAY, JUNE Meet & Greet Lecture 1: Socioeconomic-related health inequality [OO D] Health inequality stylized facts Across country health inequality Within country health inequality Explanations of health inequality o Access to medical care o Socioeconomic status as a fundamental cause o Health behaviour Trends in health inequality in the US and Europe Outline of the course Case, A and Deaton, A (2015). Rising morbidity and mortality in midlife among white non- Hispanic Americans in the 21st century. Proceedings of the National Academy of Sciences 112(49): Chetty, R et al (2016). The Association between Income and Life Expectancy in the United States, Journal of the American Medical Association 315(16): Commission on Social Determinants of Health (2008). CSDH Final Report: Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization. Currie, J and Schwandt, H (2016). Mortality Inequality: The Good News from a County-Level Approach. Journal of Economic Perspectives 30(2): Deaton, A. (2013). The Great Escape: Health, Wealth and the Origins of Inequality. Chapters 1,2 & 4. Princeton, NJ: Princeton University Press 2

3 Mackenbach, JP et al (2015). Variations in the relation between education and cause-specific mortality in 19 European populations: A test of the fundamental causes theory of social inequalities in health. Social Science and Medicine 127: Mackenbach, JP et al (2015). Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries. Journal of Epidemiology and Community Health 69: Mackenbach, JP et al (2016). Changes in mortality inequalities over two decades: register based study of European countries. British Medical Journal 353: i1732 Olshansky, S.J., Antonucci, T., Berkman, L. et al. (2012). Differences in Life Expectancy Due to Race and Educational Differences are Widening, and Many May Not Catch Up. Health Affairs 31(8): Break Lecture 2: Rank-dependent health inequality measures [OO D] (Generalised) Concentration curve (CC) (Generalised) Concentration index (CI) Analogous measures used in epidemiology O Donnell, O, van Doorslaer, E, Wagstaff, A and Lindelöw, M (2008). Analyzing Health Equity using Household Survey Data: A Guide to Techniques and Their Implementation, chapters 7 & 8. Washington, D.C.: The World Bank. [AHE] Van Doorslaer, E and van Ourti, T (2011). Measurement of inequality and inequity in health and health care, in PC Smith and S. Glied (Eds) Oxford Handbook of Health Economics, chapter 26, Oxford: Oxford University Press. [OHHE] Wagstaff A, Paci P, Van Doorslaer E (1991). On the measurement of inequalities in health. Social Science and Medicine, 33(5): Lunch (and completion of survey) Practical 1: Inference for concentration curves [OO D] Testing dominance of concentration curve against line of equality Testing dominance between independent & dependent concentration curves Computation: P1 CC.do & dominance.ado O Donnell et al (2008). AHE, chapter 7. Beach, C & Davidson, R (1983). Distribution-Free Statistical Inference with Lorenz Curves and Income Shares. Review of Economic Studies 50(4): Bishop, JA, Chow, KV and Formby, JP (1994). Testing for marginal changes in income distributions with Lorenz and concentration curves. International Economic Review 35(2): Davidson, R and Duclos, JY (1997). Statistical inference for the measurement of the incidence of taxes and transfers. Econometrica 65(5): Khaled, MA, Makdissi, P, Tabri, R and Yazbeck, M (2016). A Framework for Testing the Equality Between the Health Concentration Curve and the 45-Degree Line. mimeo University of Queensland, Khaled, M, Makdissi, P and Yazbeck, M (2016). Income-Related Health Transfers Principles and Orderings of Joint Distributions of Income and Health. mimeo University of Queensland, Break 3

4 Practical 2: Estimation and inference for the concentration index [OO D] Convenient covariance and regression Standard errors of CI estimates Computation: P2 CI.do & conindex.ado O Donnell et al (2008). AHE, chapter 8. O Donnell O, O Neill S, Van Ourti T, Walsh B (2016). Conindex: Estimation of concentration indices. The Stata Journal, 16: :15 16:30 Break 16: Lecture 3: Normative foundations of health inequality measures [TVO] Axiomatic foundation of the CI Bleichrodt, H and van Doorslaer, E (2006). A welfare economics foundation for health inequality measurement, Journal of Health Economics, 25(5): Fleurbaey, M and Schokkaert, E (2012). Equity in health and health care. in MV Pauly, TG. McGuire and PP Barros (editors), North Holland Handbook of Health Economics volume 2, chapter 16, Amsterdam: North Holland. TUESDAY, JUNE 27 09: Lecture 4: Corrected concentration indices [TVO] Taking account of measurement properties of health outcomes CIs for non-ratio-scaled health outcomes CIs for bounded health outcomes Absolute versus relative: inequality planes More axiomatic foundations Erreygers, G (2009). Correcting the concentration index, Journal of Health Economics, 2009, 28(2): Erreygers, G and Van Ourti, T (2011). Measuring socioeconomic inequality in health, health care and health financing by means of rank-dependent indices: A recipe for good practice. Journal of Health Economics, 30 (4): Erreygers, G., and T. Van Ourti. (2011). Putting the cart before the horse. A comment on Wagstaff on inequality measurement in the presence of binary variables. Health Economics 20: Kjellsson, G. (2013). On correcting the concentration index for binary variables. Journal of Health Economics 32: Kjellsson G, Gerdtham U, Petrie D (2015). Lies, damned lies, and health inequality measurements: understanding value judgments. Epidemiology, 26(5): O Donnell et al (2016). Conindex: Estimation of concentration indices. The Stata Journal, 16: Wagstaff, A (2005). The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality, Health Economics, 14, 2005, Break 4

5 10:45 12:00 Practical 3: Computation of corrected concentration indices [TVO] P3 Corrected CI.do & conindex.ado O Donnell et al (2016). Conindex: Estimation of concentration indices. The Stata Journal, 16: :00 13:15 Lunch 13:15 14:30 Lecture 5: Alternative attitudes to health inequality [TVO] Aversion to inequality, poverty and extremes Trading off health inequality and mean health Computation of extended and symmetric CIs using condindex Erreygers G, Clarke P, Van Ourti T (2012). Mirror, mirror, on the wall, who in this land is fairest of all? Distributional sensitivity in the measurement of socioeconomic inequality in health. Journal of Health Economics 31(1): Khaled, M, Makdissi, P and Yazbeck, M (2016). Income-Related Health Transfers Principles and Orderings of Joint Distributions of Income and Health. mimeo University of Queensland, Wagstaff, A (2002). Inequality aversion, health inequalities and health achievement, Journal of Health Economics 21: :30 14:45 Break 14:45 15:45 Seminar 1: Do you prefer a smaller concentration index? [TVO] Discussion based on responses to survey experiment Bleichrodt H, Rohde K, Van Ourti T (2012). An experimental test of the concentration index. Journal of Health Economics, 31(1), Gaertner W, Schokkaert E (2012). Empirical social choice: questionnaire-experimental studies on distributive justice. Cambridge: Cambridge University Press. Tarroux B (2015). Comparing two-dimensional distributions: a questionnaire-experimental approach, Social Choice and Welfare, 44(1): :45 16:00 Break Lecture 6: Decomposition of health inequality [OO D] Blinder-Oaxaca decomposition of a group difference in means Decomposition of change in a group mean difference Decomposition of the concentration index Full differential approach to decomposition of the CI Gravelle H (2003) Measuring income related inequality in health: standardisation and the partial concentration index. Health Economics, 12(10): Wagstaff, A, van Doorslaer, E, Watanabe, N (2003). On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. Journal of Econometrics, 112 (1), O Donnell, O, E van Doorslaer and A Wagstaff. (2012). Decomposition of inequalities in health and health care, in AM Jones (Ed) The Elgar Companion to Health Economics, pp Chletenham: Edward Elgar. 5

6 Evening WEDNESDAY, JUNE 28 Assignment 1: Testing CC dominance and computation of CIs using conindex [OO D] Practical 4: Solution to Assignment 1 and decomposition of the concentration index [OO D] Assignment 1.do & P4 Decomposition CI.do Break Lecture 7: CI decomposition: extensions, criticisms and alternatives [TVO] Longitudinal decompositions Criticisms of CI decomposition Decomposition based on the recentered influence function Allanson, P, Gerdtham, U-G, Petrie, D (2010). Longitudinal analysis of income-related health inequality Journal of Health Economics; 29: Baeten, S, Van Ourti, T, van Doorslaer E. (2013). Rising inequalities in income and health in China: who is left behind? Journal of Health Economics; 32: Erreygers, G and Kessels, R (2013). Regression-based decompositions of rank-dependent indicators of socioeconomic inequality of health in P. Rosa Dias and O. O Donnell Health and Inequality, Research on Economic Inequality Vol 21 pp Bingley: Emerald Group Publishing. Heckley, G, Gerdtham, U-G, Kjellsson, G. (2016). A general method for decomposing the causes of socioeconomic inequality in health. Journal of Health Economics, 48: Van Ourti, T, van Doorslaer, E, Koolman, X (2009). The effect of income growth and inequality on health inequality: Theory and empirical evidence from the European Panel. Journal of Health Economics, 28: :15 11:30 Break Practical 5: Decomposition using the recentered influence function [TVO] P5 RIF.do 12:30 13:45 Lunch 13:45 14:45 Lecture 8: Unfair health inequality [OO D] Concepts of fairness Compensation and reward Direct unfairness and the fairness gap Comparison with CI approach Direct and indirect standardisation Fleurbaey, M and Schokkaert, E (2009). Unfair inequalities in health and health care. Journal of Health Economics, 28:73-90 Fleurbaey, M and Schokkaert, E (2012). Equity in health and health care. in MV Pauly, TG. McGuire and PP Barros (editors), North Holland Handbook of Health Economics volume 2, chapter 16, Amsterdam: North Holland. 14: Break 6

7 Lecture 9: Inequality of opportunity for health [TVO] Effort and circumstances Where to draw the responsibility cut? Vertical equity How to deal with luck? And risk? Broader concepts of welfare Fleurbaey & Schokkaert (2009 & 2012) as in lecture 8 Roemer JE (2002). Equality of opportunity: a progress report. Social Choice and Welfare 19: Lefranc A, Trannoy A, Pistolesi N (2009). Equality of opportunity and luck: Definitions and testable conditions with an application to income in France. Journal of Public Economics, 93: Trannoy, A, Tubeuf S, Jusot F, Devaux M (2010). Inequality of opportunities in health in France: a first pass, Health Economics, 19: Break Practical 6: Empirical testing of equality of opportunity for health [TVO] Application based on Garcia-Gomez et al P6 EoOp.do Introduction to assignment García-Gómez P, Schokkaert E, Van Ourti T and Bago d'uva T (2015). Inequity in the face of death. Health Economics 24: THURSDAY, JUNE 29 09:00 09:45 Lecture 10: Positive economics of health inequality: theory [OO D] Can economic theory explain health inequality? Grossman model of health capital & extensions Limitations of economic theory in understanding health behaviour Grossman, Michael (1972). On the concept of health capital and the demand for health. Journal of Political Economy, 80, 2, Galama, TJ and van Kippersluis H (2013). Health inequalities through the lens of health-capital theory: issues, solutions and future directions. In P Rosa Dias and O O Donnell (Eds.) Health and Inequality, Research on Economic Inequality, Vol. 21, pp , Bingley: Emerald. Galama, TJ and van Kippersluis H (2015). A Theory of Socioeconomic Disparities in Health over the Life Cycle, CESR-Schaeffer Working Paper , 09:45 10:00 Break 7

8 10:00 10:45 Lecture 11: Positive economics of health inequality: empirics [OO D] Identification of causal effects of SES on health Education effects on health Wealth effects on health Income effects on health Adams, Peter, Michael D. Hurd, Daniel McFadden, Angela Merrill, and Tiago Ribeiro (2003). Healthy, wealthy, and wise? Tests for direct causal paths between health and socioeconomic status. Journal of Econometrics, 112, Amin, V, Behrman JR, & Kohler HP (2015). Schooling has smaller or insignificant effects on adult health in the US than suggested by cross-sectional associations: new estimates using relatively large samples of identical twins. Social Science & Medicine, 127, Cesarini D, Lindqvist E, Östling R and Wallace B (2016). Wealth, Health and Child Development: Evidence from Administrative Data on Swedish Lottery Players. Quarterly Journal of Economics, 131: Clark, D and Royer H (2013). The Effect of Education on Adult Mortality and Health: Evidence from Britain. American Economic Review, 103(6): Conti, G, Heckman JJ and Urzua S (2010) The Education-Health Gradient. American Economic Review: Papers and Proceedings 100: Grossman, Michael (2015). The relationship between health and schooling: What s new? NBER Working Paper 21609, Cambridge MA: NBER O Donnell, O, van Doorslaer E and van Ourti T (2015). Health and Inequality in A.B. Atkinson and F.J. Bourguignon (eds.) Handbook of Income Distribution volume 2B, chapter 17, Amsterdam: North Holland, [in Blackboard folder.] Stowasser, T, Heiss F, McFadden D and Winter J (2012). Healthy, Wealthy, and Wise? Revisited: An Analysis of the Causal Pathways from Socio-Economic Status to Health. In D.A. Wise (ed.), Investigations in the Economics of Aging. University of Chicago Press, pp : Break Lecture 12: Explaining social inequalities in health: an epidemiological perspective [SS] Behavioral, Environmental and Psychosocial explanations A lifecourse perspective The biological consequences of social inequalities Stringhini S, Dugravot A, Shipley M, Goldberg M, Zins M, Kivimäki M, et al. (2011) Health Behaviours, Socioeconomic Status, and Mortality: Further Analyses of the British Whitehall II and the French GAZEL Prospective Cohorts. PLoS Med 8(2): e PMID: Siegrist J, Marmot M (2004). Health inequalities and the psychosocial environment two scientific challenges, Social Science & Medicine, 58(8): , PMID: Evans GW, Kantrowitz E (2002) Socioeconomic Status and Health: The Potential Role of Environmental Risk Exposure Annual Review of Public Health 23(1): PMID: Stringhini S, Polidoro S et al (2015). Life-course socioeconomic status and DNA methylation of genes regulating inflammation. International Journal of Epidemiology 44(4): doi: /ije/dyv060 PMID: H. Dike Van De Mheen, Karien Stronks and Johann P. Mackenbach (1998). A lifecourse perspective on socio-economic inequalities in health: The influence of childhood socio-economic conditions and selection processes. Sociology of Health and Illness 20(5):

9 12:30 13:45 Lunch 13:45 15:00 Lecture 13: Health determined economic inequality [OO D] Reverse causality and health selection hypothesis Health work & wages Disability insurance Life cycle profile of income gradient in health Health (medical expenses ) wealth Dobkin C, Finkelstein A, Kleunder R and Notowidigdo MJ (2016). The economic consequences of hospital admissions. NBER Working Paper 22288, Cambridge, MA: NBER. Currie, Janet (2009) Healthy, wealthy, and wise: socioeconomic status, poor health in childhood, and human capital development. Journal of Economic Literature 47(1): Garcìa Gòmez, P, van Kippersluis H, O'Donnell O & van Doorslaer E (2013). Long term and spillover effects of health on employment and income. Journal of Human Resources, 48(4): van Kippersluis H, O Donnell O, van Doorslaer E and Van Ourti T (2010). Socioeconomic difference in health over the life cycle in an egalitarian country. Social Science and Medicine 70: O Donnell O, van Doorslaer E and van Ourti T (2015). Health and Inequality in A.B. Atkinson and F.J. Bourguignon, Handbook of Income Distribution volume 2B, chapter 17, pp , Amsterdam: Elsevier, Smith, JP (1999). Healthy bodies and thick wallets: The dual relation between health and socioeconomic status. Journal of Economic Perspectives, 13, Smith JP (2005). Unravelling the SES-health connection. Population and Development Review 30: Students work on assignment FRIDAY, JUNE Lecture 14: Measurement of inequity in health care [TVO] Legitimate and illegitimate variation in health care Horizontal and vertical conceptions of equity Need standardisation (direct and indirect) Measurement and decomposition of inequity Decomposition with nonlinear models Allowing for heterogeneity in need effects O Donnell et al (2008). AHE, chapter 15 Van Doorslaer & van Ourti (2011). OHHE Fleurbaey, M. and E. Schokkaert (2009). Unfair inequalities in health and health care Journal of Health Economics, 28:73-90 Van Doorslaer, E, X Koolman, AM Jones, Explaining income-related inequalities in health care utilisation in Europe: a decomposition approach, Health Economics, (7) Bago d Uva, T., AM Jones and E van Doorslaer Measuring horizontal inequity in health care utilisation using European panel data. Journal of Health Economics, 28(2): E. Van de Poel, E. van Doorslaer and O. O Donnell, Measurement of Inequity in Health Care with Heterogeneous Response of Use to Need, Journal of Health Economics, 31(4): Wagstaff & van Doorslaer NHHHE Break 9

10 Seminar 2: Policy response to health inequality [OO D] What do we learn from measures of SES-related health inequality? What role should they play in health and social policy formation? Can health disparities be addressed by income redistribution policy? Is health an important determinant of economic inequality? Can health disparities be addressed by social insurance? Student presentations and evaluation I [TVO, OOD] Lunch Student presentations and evaluation II [TVO, OOD] Break Student presentations and evaluation III [TVO, OOD] 10