The Health Effects of Social and Economic Policy

Policy Brief#20, September 2009

The National Poverty Center’s Policy Brief series summarizes key academic research The Health Effects of Social and Economic findings, highlighting implications for policy. Policy: The Promise and Challenge for The NPC encourages the dissemination of Research and Policy this publication and grants full reproduction right to any party so long as proper credit James S. House, Robert F. Schoeni, George A. Kaplan, and Harold Pollack. Based on a chapter in is granted the NPC. Sample citation: “Title, Robert F. Schoeni, James S. House, George A. Kaplan, and Harold Pollack (editors), 2008. Making National Poverty Center Policy Brief #x”. Americans Healthier: Social and Economic Policy as Health Policy. New York: Russell Sage.

The United States spends more on health health care is the major determinant of Highlights insurance and medical care as a percent of health. As dramatic and consequential

• It is increasingly hard to justify not GDP than any other nation. Yet despite as medical care is for individual cases, considering potential health impacts of the marked growth in spending over the much evidence suggests that such care policy change given the range and size of past fifty years, the U.S. has fallen from is not, and probably never has been, the potential health outcomes that flow from all being amongst the top in life expectancy major determinant of overall levels of policy, including policies that are seemingly and infant mortality to ranking at or near population health. Rather, economic, unrelated to health. the bottom among developed nations. social, psychological, behavioral and • Non-health related policies may have Of the thirty nations in the OECD, only environmental factors are more likely the positive consequences for health that Mexico, Turkey, and three former Soviet major determinants of population health. are equally or more important than the bloc countries consistently rank below the outcomes they were originally designed to produce. Thus, health effects can be central U.S. on such indicators. Historical Perspective factors in decisions concerning changes in A brief historical review is helpful in Most political and policy analysis related policy seemingly unrelated to health. understanding why and how social and to health in the United States focuses economic policies may be just as important • Health research and policy in the United on medical-care and insurance. Little as health policies in maintaining and States should shift towards models recently attention is paid to levels of population adopted in Canada, Sweden and the broader improving population health. health beyond the worry that spending European Union that consider and evaluate the health impact of all policy, not just constraints may adversely affect it. The Between the mid-eighteenth and mid- health policy. concentration of policy discussion on nineteenth centuries, and accelerating medical services however, ignores historical in the first half of the twentieth century, • Social and economic policy can present alternatives to increased health care spending facts about the causes of major changes in human life expectancy in Europe and for maintaining and improving health. By the overall health of populations. It also North America grew at unprecedented considering the health impacts of public and neglects very real opportunities outside the rates. Although this roughly coincided with private policies not directly related to health domain of medical care to improve health. the development of modern biomedical care as mechanisms for promoting health The idea that a country could achieve science and its translation to health care and preventing or alleviating disease, the cost-effectiveness of non-health policies can better population health without explicitly practice, most of the improvement for also be greatly enhanced. increasing health care spending may seem many diseases actually occurred prior paradoxical, but only if we assume that to, and independently of, the discovery

Gerald R. Ford School of Public Policy, University of Michigan www.npc.umich.edu of the causative bacterial or viral agents, germ theory of disease, combined with the Not surprisingly, socioeconomic position and the application of this knowledge in general decline of dread diseases between shapes people’s experience of, and exposure the form of vaccines or pharmacological the mid-nineteenth and mid-twentieth to, almost all risk factors for poor health treatment (McKinlay and McKinlay 1977; centuries, led nonetheless to the hegemony (Marmot, Bobak and Smith 1995; Lynch et Preston 1977). In fact current estimates of the biomedical perspective on health in al. 1996; House and Williams 2000). suggest that only about five years of the the U.S. and many other developed nations. Current research on the psychosocial, almost thirty-year increase in U.S. life Understanding microbiological basis of biomedical, and environmental expectancy over the twentieth century were life and disease seemed to provide a golden determinants of health has moved in two due to preventive or therapeutic medicine pathway to improved population health. directions. The more common approach (Bunker, Frazier, Mosteller, 1994). The The rise of modern “epidemics”— might be referred to as “downstream,” that exact nonmedical factors responsible for particularly heart disease and cancer— is, seeking to understand the mechanisms the great historical rise in life expectancy began to cloud this picture in the mid- through which psychosocial risk factors are impossible to identify retrospectively, twentieth century. As a result, several affect health. This approach tends to lead but general socioeconomic development— strands of research which recognized the to a biomedical approach to mitigating most notably improvements in nutrition, role of socioeconomic and psychosocial the health impact of social or economic sanitation, housing and clothing, and determinants of health were revived. In risk factors—for example, finding a general conditions of life, certainly played particular, a strand of research by Hans pharmacological treatment for stress. a central role. The scientific success of the Selye (1956) and others showed that An “upstream” approach, on the other perturbations in the relation between hand, seeks to understand the broader Figure 1. organisms and their psychosocial, as well aspects of social life that shape exposure U.S. Infant Mortality Ranking as their physical, chemical, and biological to such psychosocial or environmental environments led to physiological risk factors. Many public policies strongly symptoms in the form of, for example, impact health because they strongly impact heightened heart rate or blood pressure. the socioeconomic, psychosocial, and/or These symptoms in turn could lead to environmental determinants of health. physical disease and even death. The rise Very few policy makers have considered of chronic diseases ultimately produced health in either formulating or justifying a change in the epidemiologic conception public policies. The authors hope to change of, and search for, their causes—a shift this state of affairs by encouraging a from identifying a single causative agent proactive identification—and perhaps also to identifying multiple contingent causal mitigation or enhancement—of the health Source: authors’ compilation from OECD Health Statistics (2006) forces, or risk factors. Though biological impacts of social and economic policies. risk factors (i.e. blood pressure, cholesterol) Figure 2. were the central focus of attention initially, The Promise Ratio of GDP Spent by U.S. increasingly behaviors (such as tobacco use and the Challenges to Rest of OECD average or a sedentary life-style), have also been A greater and more specific focus on the identified as high risk factors for various actual and potential health effects of social chronic diseases. Perhaps the most striking and economic policy could strengthen and important development in social scientific understanding of the determinants epidemiology over the last quarter century of health as well as their amenability to has been the discovery (or rediscovery) change via public policy. It could also help of large, persistent and even increasing extricate American health policy from disparities in health by socioeconomic unparalleled levels of spending growth with status and race-ethnicity (Marmot, little to show for it. Social and economic Kogevinas, and Elston 1987; Pappas et policy may well be a more cost-effective way al. 1993; Wilkinson 1996; Kaplan and Source: authors’ compilation from OECD Health Statistics (2006) of improving population health. Lynch 1997; House and Williams 2000).

www.npc.umich.edu 2 Realizing this promise requires confronting efforts outside the traditional realm of Health Policy, eleven chapters are devoted a number of challenges. Determining health—from taxation to restrictions on to examining the linkages between causality is the first. The inherent difficulty where and when people could advertise, population health and several ostensibly in proving that a particular social or buy, and use tobacco products—proved “non-health” policy arenas. Six key policy economic policy or program impacts health more feasible and cost-effective than areas with potentially sizable effects on is complicated by competing approaches medical attempts to somehow block the health are addressed: education policy, to determining causality. One view holds adverse effects of tobacco smoke. income-support policy, civil-rights that the only way to establish a causal policy, macroeconomic and employment One reason economic and social policy relationship is through randomized policy, welfare policy, and housing and is less frequently employed as a tool experimentation, or a close approximation. neighborhood policy. The authors of these for improved health is that while there A different tradition derives its power from chapters seek to assess where we are, and is a well-established paradigm and a an accumulated body of evidence showing where we might most fruitfully go next in supportive institutional structure for basic consistency of statistical association across order to better understand whether, why biomedical research and its translation a wide number of studies. Both approaches and how certain policies and programs to health policy and practice, nothing have value, and increased engagement impact health. approaching this exists for social or and interchange between the two is economic determinants of health. This In commissioning the chapters in this crucial. A second challenge has to do with has deleterious consequences for both volume, the authors sought to provide cost-effectiveness. Even if we determine scientific understanding and potential a foundation for a more comprehensive causality, it is possible that achieving a improvements in health. Even when basic American health policy. Just as we now desired health impact may be too costly research provides strong evidence of the routinely evaluate the environmental relative to its putative effects. The health health impact of socio-economic factors, impact of programs and policies not effects of social and economic policy must there is no infrastructure to systematically explicitly environmental in nature (Irwin be evaluated not only absolutely, but also translate these findings into policy and and Scali 2005), the United States must relative to not being implemented, and practice. We need to foster the social move toward models recently advocated relative to other programs and policies and economic equivalent of clinical trials and adopted in Canada, Sweden and the specifically aimed at health. Next, even through the experimental introduction and broader European Union that consistently if a non-health policy or intervention is evaluation of potential new policies and consider evaluating the impact of all recognized as both causal and cost-effective programs. Though some well known—and policy—not just health policy—on health with respect to health, an objection may highly regarded—social experiments outcomes (Raphael and Bryant 2006; be raised that it is simply politically, have been conducted (the Negative Navarro 2007). In so doing, we might technically, or otherwise unfeasible. Income Tax and MDRC welfare-reform just help our nation escape the dubious The case of cigarette smoking provides a evaluations come to mind), they have distinction of having the highest healthcare fascinating example of how policies not typically been implemented with a focus expenditures in the world coupled with the specifically aimed at health can impact on specific outcomes relative to the income worst public health outcomes of any major it. Originally U.S. policy addressing maintenance and/or welfare-reform debate. industrial democracy. cigarettes had little or nothing to do with Had they also explored health outcomes health, but much to do with agriculture they would have been even more valuable. References and commerce. As smoking increased, Bunker, John P., Howard S. Frazier, and likely due at least in part to these policies, The Linkages Between Frederick Mosteller. 1994. “Improving evidence suggesting that the concurrent Non-health Policy Areas Health: Measuring Effects of Medical increase in chronic disease might be related Care.” The Milbank Quarterly 72(2); 225-58. to smoking began to mount. Though it and Health House, James S. and David R. Williams. took decades, causality was eventually A growing body of evidence suggests that 2000. “Understanding and Reducing determined. But even as consensus grew, social and economic policy and practice Socioeconomic and Racial/Ethnic many doubted that it was technically, may be the major route to improving Disparities in Health.” In Promoting politically or ethically feasible to reduce population health. In Making Americans Health: Intervention Strategies from Social the consumption of cigarettes. In the end, Healthier: Social and Economic Policy as

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Kaplan, George A. and John W. Pappas, Gregory, Susan Queen, William Lynch. 1997. “Whither Studies on the Hadden, and Gail Fisher. 1993. “The Socioeconomic Foundations of Population Increasing Disparity in Mortality Between Health.” In Closing the Gap: The Burden Socioeconomic Groups in the United of Unnecessary Illness, edited by Robert States, 1960 and 1986.” New England Journal Q. Amler and H. Bruce Dull. New York: of Medicine 329(2):103-9. Oxford University Press. Preston, Samuel H. 1977. “Mortality Irwin, Alec, and Elena Scali. 2005. “Action Trends.” Annual Review of Sociology 3: 163-78. on the Social Determinants of Health: Raphael, Dennis and Toba Bryant. 2006. Learning from Previous Experiences, A “The State’s Role in Promoting Population Background Paper Prepared for the WHO Health: Public Health Concerns in Commission on Social Determinants of Canada, USA, UK, and Sweden.” Health Health.” Geneva: Commission on Social Policy 78(1): 39-55. Determinants of Health, World Health Organization. Selye, Hans. 1956. The Stress of Life. New York: McGraw-Hill. Lynch, John W., George A. Kaplan, Richard D. Cohen, Jaakko Tuomilehto, Wilkinson, Richard G. 1996. Unhealthy and Jukka T. Salonen.1996. “Do Societies: The Afflictions of Inequality. New Cardiovascular Risk Factors Explain York: Routledge. the Relation Between Socioeconomic Status, Risk of All-Cause Mortality, Cardiovascular Mortality, and Acute Myocardian Infarction?” American Journal of Epidemiology 144(10): 934-42. Major funding for the National Poverty Center Marmot, Michael G., Manolis Kogevinas, is provided by the Office of the Assistant and Mary Alan Elston. 1987. “Social/ Secretary for Planning and Evaluation, U.S. Economic Status and Disease.” Annual Department of Health and Human Services. Review of Public Health 8: 111-35.

Marmot, Michael G., Martin Bobak and George Davey Smith. 1995. “Explanations for Social Inequalities in Health.” In Society and Health, edited by Benjamin C. Amick III, Sol Levine, Alvin R. Tarlov, and Diana C. Walsh. New York: Oxford University Press. National Poverty Center McKinlay, John B. and Sonja J. McKinlay. Gerald R. Ford School of Public Policy 1977. “The Questionable Contribution University of Michigan of Medical Measures to the Decline of 735 S. State Street Mortality in the United States in the Ann Arbor, MI 48109-3091 Twentieth Century.” Milbank Memorial 734-615-5312 Fund Quarterly 55(3): 405-28. [email protected]