As the results in table 4 clearly demonstrate, accounting for racial composition—as measured through the individual clustering of racial groups—does not explain the state income inequality-health relation. Wilkinson RG. The authors thank Harvey Goldstein and Jim Ware for our exchanges with them with regard to comparisons of modeling strategies and Mah-J. MULTILEVEL STUDIES OF INCOME INEQUALITY AND HEALTH: WHAT DOES THE EVIDENCE TELL US? Other studies suggest that income inequality is particularly detrimental to the health of poor or near-poor individuals (19, 22). FIGURE 2. Individual demographic and socioeconomic markers account for about 35 percent of the unconditional state-attributable variation, reducing the residual variation to be explained by state-level variables to 1.4 percent. When income is specified as deciles and as quintiles, the estimated odds ratio is 1.29 (models 5 and 6). § Adjusted for individual age, sex, marital status, race, years of education, equivalized household income categories, covered by health insurance, and state median income. By analysing panel data using county/city-level dummies and year fixed-effects, we found that income inequality does not have a significant impact on individuals' risks of having health problems. Our purpose in this paper is to assess whether or not wider income differences play a causal role leading to worse health. Being obese can have a serious impact on mental and physical health. Some observers have suggested that the relation between income inequality and poor health is confounded by differences in educational attainment (45, 59). Income inequality and individual health: evidence from the Current Population Survey. † All models controlled for 1995/1997 individual age, sex, marital status, race, years of education, equivalized household income categories, covered by health insurance, and 1990 state median income. The society and population health reader. Jones K, Duncan C, Twigg L. Evaluating the absolute and relative income hypothesis in an exploratory analysis of deaths in the Health and Lifestyle Survey. Milyo J. Indeed, there is nothing artifactual about improving the health of the poor and, hence, average population health through income and wealth redistribution. for counties and tracts not reported), 279,066 adults nested within 50 US states, Behavioral Risk Factor Surveillance System (1990), Hypertension, smoking, sedentarism, body mass index, National Maternal and Infant Health Survey (1991), National Health Interview Survey–National Death Index-linked study (1987–1995), 309,135 adults aged 25–74 years from US states and metropolitan areas (no. Considering income in terms of transformed log yields an odds ratio of 1.30 (model 3), while a nonlinear specification in the form of a second-order polynomial yields an odds ratio of 1.31 (model 4). The Gini coefficient can also be illustrated through the use of a Lorenz curve (figure 1). Interestingly, almost all the non-US countries listed in table 2 are considerably more egalitarian in their distribution of incomes compared with the United States, and they have stronger safety-net provisions. Copyright © 2020 Elsevier B.V. or its licensors or contributors. In this review, however, we focus on the question: Does the unequal distribution of income in a society pose an additional hazard to the health of the individuals living in that society? Rather, they distinguish the “concavity-induced income inequality effect” from that related to the “income inequality as a societal effect.” Distinguishing the “concavity effect” of income inequality from the “pollution effect” of income inequality, meanwhile, requires multilevel data, with information gathered on both individual incomes and the extent of income inequality in the society within which the individual resides. Income inequality in the U.S. has grown over the past several decades. Request PDF | On Jul 1, 2006, N. M. Rimashevskaia and others published Income Inequality and Health | Find, read and cite all the research you need on ResearchGate Third, there is the policy pathway, whereby the adverse influence of income inequality may operate through formulation and implementation of general social policies, as well as through health-related policies. In the past 30 years, the proportion of wealth held by those in the top 10% of household income has risen from 60.8% to 70.0%. No association of income inequality with adult mortality within New Zealand. What difference does the choice of modeling strategy make to the point estimates of state income inequality? Income inequality and health: multilevel analysis of Chilean communities. However, since the objective here was to maintain uniformity across the different tests, the models were recalibrated for this review. A number of policy variables, such as primary health care indicators, welfare spending, child care, food assistance, vocational training, remedial training, health insurance, early childhood education, disability assistance, tax policy, and unemployment compensation, could mediate the relation between income inequality and health outcomes. Kawachi I, Kennedy BP, Wilkinson RG. 2 CommuniCating about the SoCial DeterminantS of health: inCome inequality anD health 1 about this booklet Communication is a core competency for public health. From the Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA. It meets established epidemiological and other scientific criteria for causality. Fifth, with regard to the published multilevel studies in the United States, the state-level income inequality has been linked to a broad variety of health outcomes, ranging from mortality (22) and self-rated health (19, 21, 24, 25) to depressive symptoms (21), hypertension, smoking, body mass index, and sedentary behavior (18) (table 1). Social cohesion, social capital, and health. Historical income tables for states: table S4. Moreover, the success of much philanthropy (e.g., donating money to provide vaccines to the world’s poor) rests on the validity of this assumption. On the horizontal axis (abscissa), the population (in this case, households) is sorted and ranked according to income, from the lowest decile group to the top decile group. Meanwhile, it is well known that the interpretation of the β coefficients is different in a multilevel and a marginal model. The median accumulated wealth of families in the top 10 percent of the income distribution was 12 times that of lower-middle-income families through much of the 1990s, but in 2001, the median net worth of the top earners was about 22 times as great (3). Goldstein H. Multilevel statistical models. It is also acknowledged that the relation between individual income and health status is concave, such that each additional dollar of income raises individual health by a decreasing amount. New York Times Jan 23, 2003:C1. More systematic work is required to unpack such interactions by key individual demographic and socioeconomic factors. As shown in table 2, studies outside the United States have been primarily confined to smaller geographic scales (e.g., parishes within a single city (34)) at which one would not necessarily expect to find variations in political behavior or policy-making according to differences in income distribution. It is widely acknowledged that individual income is a powerful determinant of individual health. In: Berkman LF, Kawachi I, eds. Various long term studies have established that this relationship is largely causal - higher income leads to better health. It must be noted that use of multilevel data has not always involved adopting an explicit multilevel analytical model of the form specified in equation 3. # The model additionally controlled for the individual markers and state median income. ¶ Gini coefficient, an income inequality indicator. The Luxembourg Income Study provides a rigorous cross-national comparison of income distributions, using a summary measure called the decile ratio, which represents the ratio of the disposable income of the person at the 90th percentile of the distribution within each country to the income of the person at the 10th percentile (36): The higher the decile ratio, the greater the social distance between the top and bottom in society and the more unequal is the societal distribution of income. We used MLwiN 1.10.0006 software (Institute of Education, University of London, London, United Kingdom) to calibrate the multilevel logistic model. If incomes in a population are distributed completely equally, the Gini value is 0, and if one person has all the income (the condition of maximum inequality), the Gini is 1.0. Recent trends in wealth inequality have been equally noteworthy. We must emphasize that any discussion of inequality and health, in general, cannot be divorced from the fundamental question of “inequality of what?” (9, 75). Accordingly, we examined the associations between state-level income inequality and poor health under different assumptions about lag periods. CrossRef Google Scholar Approximately 15 percent of the Current Population Survey sample population reported being in fair/poor health. Author information: (1)New York University, Steinhardt School of Education, USA. Diez-Roux AV, Link BG, Northridge ME. Lagged effects of income inequality on individual and population health. We start, however, by briefly rehearsing the conceptual basis for the relation between income inequality and health. However, it has been argued that the “proportion Black” in a state confounds the income inequality-health relation (47, 62). Historical income tables for states: table S1. Consequently, researchers have posited that an aggregate relation between the average health status of a society and the level of income inequality in a society could be observed if the individual-level relation between income and health (within society) is concave. The above distinctions, therefore, are not between the “effects of individual income” on health and the “effect of income inequality” on health. Random-effects models for longitudinal data. We used SUDAAN 8.0.1 software (Research Triangle Institute, Research Triangle Park, North Carolina) to calibrate the marginal logistic model. The health of nations. Our intent here is not to provide a detailed assessment of each study. Therefore, the population health impacts of income inequality are potentially widespread, much like the impacts of income poverty on health outcomes. studied 90,000 (24) and 201,221 (25) subjects. The term “multilevel models” is used to represent models that explicitly recognize the nested structure of the data in the data, and the potential clustering in individual observations is of substantive interest and hence modeled explicitly. Aberg YM, Fritzell J, Lundberg O, et al. In economics terms, income inequality is the large disparity in how income is distributed between individuals, groups, populations, social classes, or countries. Median household income by state: 1969, 1979, 1989. When we turn to countries that are relatively more unequal than the United States (e.g., Chile (table 2)), we find some support for the relation (37). for parishes not reported), Japanese Survey of Living Conditions of the People on Health and Welfare (1995), 80,899 adults from Japanese prefectures (no. Reducing income inequality will improve population health and wellbeing. * The term “single-level regression” is used in a generic sense to represent models that ignore the nested structure of the data and thereby the clustering in the individual observations; as such, the functional form of the outcome— whether it is linear, binary, or count—is not relevant. Across the six different specifications of individual-level income, therefore, the differences in odds ratio for poor health associated with a 5 percent increase in the Gini coefficient were not substantial, suggesting that the relation between state income inequality and individual health is independent of the income-health relation at the individual level. While these studies may have lacked statistical power, we also hasten to add that the lack of an association between income inequality and health at levels below the US states may be attributable to a true absence of an association (a finding corroborated in studies that were adequately powered, for instance, at the metropolitan area level (16)). In: Berkman LF, Kawachi I, eds. Kawachi I, Kennedy BP. A multilevel analysis of income inequality and cardiovascular disease risk factors. Lynch J, Davey Smith G. Commentary: income inequality and health: the end of the story? A simultaneous three-equation model is specified between GDP per capita (GDPc) level, infant mortality rate and health expenditures for 194 countries from 1990 to 2014. One reason health care inequality in America is so high is that it's the only developed country that relies on private health insurance. Lochner K, Pamuk ER, Makuc D, et al. for municipalities not reported), 8,720 adults nested within 207 UK constituencies nested within 22 regions, Two cohort studies in Copenhagen, Denmark (1964–1992, 1976–1994), 25,728 adults from parishes within Copenhagen city (no. Second, there is growing scholarly and public recognition that many nonclinical factors—education, employment, race, ethnicity, and geography—influence health outcomes. Santa Monica, CA: Unicon Research Corporation, 1998. There is a very large literature examining income inequality in relation to health. 3rd ed. The odds ratio is 1.31 when a linear effect of individual income is assumed (model 2). Andrews EL. Income and wealth inequality in the United States has been on the rise since the early 1970s, 7 and even prior to the pandemic it showed no sign of abating. Specifically, we collected and digitised a series of publications listing individual income declarations for 24 Italian provinces composed of around 2,000 municipalities in 1924. Lobmayer P, Wilkinson RG. Published multilevel studies on the relation between income inequality and health outside the United States, Odds ratios and 95% confidence intervals for reporting fair/poor health (outcome) for a 5% change in US state Gini coefficient* under alternate specifications of the individual-level relation between income and self-rated fair/poor health†. These issues, nonetheless, raise important questions for interpreting context-attributable variation, in general. Despite the fact that almost all of the studies listed in tables 1 and 2 controlled for individual income, skepticism has been expressed about whether the apparent association between income inequality and health could be due to misspecification of individual income and residual confounding (57). The individual-level relation between income and health. In recent times, the collective attribute of social relations has been conceptualized through the idea of “social capital” (70, 71). This result is robust when changing between different indicators for income inequality. Education, income inequality, and mortality: a multiple regression analysis. Metropolitan area income inequality and self rated health—a multilevel study. Other axes of stratification (or hierarchy), such as the unequal distribution of wealth, political power, cultural assets, social assets, honorific status, human capital (to name a few), could also be important determinants of health outcomes (9). Strict comparisons across these studies are not possible, given differences in methods, model specifications, and the incomplete nature of information provided by study authors. The causal processes may extend to violence and other problems with social gradients. The state-level associations seem to suggest the importance of political mechanisms, such as the relation of economic disparities within each state to patterns of spending by state legislatures on social goods such as health care, education, and welfare. Published multilevel studies on the relation between income inequality and health within the United States. The three pathways, moreover, need not be mutually exclusive. These findings suggest that, while individual race, educational attainment, and income attenuate the baseline effect of state income inequality, they do not fully account for the observed association between self-rated poor health and state income inequality in the United States. New York, NY: Oxford University Press, 2003:65–111. Using the Current Population Survey data, which include very detailed information on individual income, we tested the extent to which the relation between state-level income inequality and poor health in the United States is sensitive to alternative specifications of individual income (table 3) (58). Oxford University Press is a department of the University of Oxford. The theory, as well as empirical investigations of income distribution and health, can be usefully extended by a more systematic examination of the issue of what levels matter for population health and why. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. Does the state you live in make a difference? Over and above these generic challenges of demonstrating a causal effect of income inequality on health, we highlight in this section a set of issues that promises to take the field forward in new directions. Of the 21 studies drawing upon multilevel data listed in the two tables, only eight studies (16–18, 24, 25, 33, 35, 37) appropriately recognize the true multilevel structure of the data while modeling the effect of income inequality on health. London, United Kingdom: Multilevel Models Project, Institute of Education, University of London, 2000. For example, in the study by Fiscella and Franks (26), based on 14,407 adults in the National Health and Nutrition Examination Survey, the 95 percent confidence intervals around the mortality hazard ratio for county-level income inequality were quite wide (point estimate: 0.81, 95 percent confidence interval: 0.22, 2.92). The aim in this review was, nevertheless, to focus on the literature that has investigated the empirical relation between income inequality and health. Health inequities are unfair and could be reduced by the right mix of government policies. Kawachi I, Kennedy BP. (In figure 1, it takes the bottom half of the households to account for just 10 percent of the aggregate income.) The macroeconomic determinants of health. between income inequality and health and social problems (Saunders, 2010; Snowdon, 2010). Subramanian SV, Kawachi I. Natural experiments, such as the recent rounds of tax cuts in the United States, may provide future opportunities to examine the impact of changes in income distribution on changes in population health outcomes. With the fixed part specification being kept constant across the different modeling strategies, the point estimates for state income inequality from a simple binary logistic model (one that ignores the state-attributable variation) and the marginal binary logistic model (one that adjusts for the state-attributable variation but does not model it explicitly) were similar (β = 3.75), with the associated standard errors being substantially underestimated in the simple binary logistic model (standard error, 0.35) (table 9). Previous multilevel studies, however, found that individual differences in educational attainment did not explain away the association between state income inequality and poor health status (24, 25, 61). Moreover, the fact that the magnitude of the income inequality effect (and in some cases the sign of the mortality-income inequality relation) changes between the two time periods necessitates a cautious interpretation of these results. Subramanian SV, Belli P, Kawachi I. Indeed, such a transfer also implies a reduction in the income inequality level in that particularly society and, as such, the society with the narrower distribution of income will have better average health status, all other things being equal (9). Under conditions of perfect equality in the distribution of income (Gini = 0), each decile group would account for exactly 10 percent of the aggregate income, such that the Lorenz curve would follow the 45-degree line of equality. Sen AK. The independent effect of income inequality on health/social problems shown in some studies looks small in statistical terms. Mellor JM, Milyo J. Reexamining the evidence of an ecological association between income inequality and health. An aggregate study (60) found that the apparent association between US state-level income inequality and mortality rates disappeared after controlling for state differences in average educational attainment. We have demonstrated elsewhere that racial composition—whether measured as individual clustering of races within states or measured as proportion Black—does not account for the state income inequality-health relation (25, 58). Effective communication can increase the awareness, understanding, and action on the London, United Kingdom: Ashgate Press, 2004. Breaking the possible negative relationship between income inequality and health status in these countries makes health promotion policy and positive income–health path to develop smoothly. New York, NY: WW Norton & Company, 2003. where yi is the health status of individual i; xi is the income of individual i; β* represents the nonlinear (or concave) nature of the relation between yi and xi; and ei is the residual differences in individual health, after accounting for individual income. Wagstaff A, van Doorslaer E. Income inequality and health: what does the literature tell us? We have previously reported some of the key results discussed in this section. We tested the income inequality hypothesis to answer the research questions. It meets established epidemiological and other scientific criteria for causality. Evidence that income inequality is associated with worse health is reviewed. (27) was based on a comparatively small sample of about 6,500, with 341 deaths in the first period and 375 deaths in the second period. Narrowing the gap will improve the health and wellbeing of populations. Interpreting parameters in the logistic regression model with random effects. As we have argued, the answer to that question depends on a combination of better data, more sophisticated analytical methods, and more rigorous application of theory and mechanisms connecting income inequality to public health. Hence, throughout the rest of this review, we shall use the term “concavity effect” to describe the expected relation between income inequality and population average health status, when the shape of the association between individual income and health is concave. It is noteworthy that few investigators have attempted to dissect the cross-level interactions between area-level inequality and the health of particular sociodemographic groups. We use cookies to help provide and enhance our service and tailor content and ads. In the United States, health and health care inequality is correlated with income inequality. One conclusion, in this instance, is that models that did not explicitly model the state-attributable variation underestimated the state income inequality effect with an odds ratio of 1.21 as compared with an odds ratio of 1.30 from a multilevel model. Multilevel analysis of self-rated health in the U.S. Subramanian SV, Blakely T, Kawachi I. Gini ratios by state: 1969, 1979, 1989. Meanwhile, the aggregate (societal) level relation between income inequality and health can be expressed in the following way: where yj is the average health of a society j; Wj is the income inequality in society j; α estimates the relation between yj and Wj; and uj is the residual differences in societal health, after accounting for societal level income inequality. Subramanian SV, Kawachi I. Thousand Oaks, CA: Sage Publications, 2002. First, in a comparison of tables 1 and 2, it is evident that the bulk of studies that suggest an association between income inequality and poor health have been conducted so far within the United States (16–25). Of the small minority of studies which find no association, most can be explained by income inequality being measured at an inappropriate scale, the inclusion of mediating variables as controls, the use of subjective rather than objective measures of health, or follow up periods which are too short. Using typical regression notations, we can specify the individual-level relation between income and health as follows: yi = β*(xi) + ei, (1). New York, NY: The New Press, 2003. (22) studied 546,888 subjects, and Subramanian et al. The evidence at lower levels of aggregation, such as metropolitan areas (16), counties (26), and census tracts (20), is decidedly mixed. Washington, DC: National Policy Association, 1998:194–217. Social epidemiology. and Milyo, J. Early reviews came to different interpretations of the evidence, though a large majority of studies reported that health tended to be worse in more unequal societies. Income Inequality Definition . Mellor JM, Milyo J. We also generate a measure of inequality at the municipality level by relying on a unique historical source of information on Italian incomes. § In this modeling strategy, the potential clustering of individuals within states is ignored. The point estimates for state income inequality from both these models, meanwhile, were underestimated when compared with the point estimate associated with state income inequality estimated from a two-level binary logistic model, with the state-attributable variance being explicitly modeled (β = 5.26) (table 9). ‡ All models additionally controlled for individual age, sex, marital status, race, years of education, covered by health insurance, and state median income. Change in the odds ratios and 95% confidence intervals for reporting fair/poor health (outcome) for a 5% change in US state Gini coefficient* and for a 5% change in proportion Black under alternative specifications of racial composition†. We summarize the published multilevel studies of income inequality and health in tables 1 and 2. We know that people with higher incomes are healthier. Random parameter estimates of the between-state variation, % state-attributable variation, and % change in between-state variation with sequential introduction of predictors in the fixed part of a multilevel logistic model with self-rated fair/poor health as an outcome*. Income inequality as a public health concern: where do we stand? ¶ The equivalized household income categories ($) were as follows: ≥75,000 (reference); 50,000–74,999, 30,000–49,999, 15,000–29,999, <15,000. For comparability, the studies have been grouped according to those conducted within the United States (table 1) and those outside the United States (table 2). ‡ Model additionally controlled for 1995/1997 individual age, sex, marital status, race, years of education, equivalized household income categories, covered by health insurance, and 1990, 1980, and 1970 state median income, respectively. The more consistent association between state-level income inequality and health in the United States provides some clue about the pathways and mechanisms by which income distribution affects population health, an aspect that we shall return to later in this review. Smeeding TM. Inequality reexamined. where yij is the health status of individual i in society j; xij is the income of individual i in society j (with β* estimating the nonlinear (or concave) nature of the relation between yij and xij within a society); and Wj is the level of income inequality in society j (with α estimating the effect of societal income inequality on individual health) having taken account of the individual income-health relation. While American society is getting more, and not less, segregated (68) and getting more unequal (39), there is, however, little systematic empirical research that has explored the connections between the two and their influence on health. Income inequality measure. Oxford, United Kingdom: Clarendon Press, 1993. Doing so resulted in a much attenuated association between state-level income inequality and health. Soobader and Stephen Gilman for their assistance with calibrating the marginal logistic model reported in this review. By contrast, studies that found an association between state-level income inequality and mortality have tended to involve larger numbers. Applying this three-level multilevel structure (individual nested within states nested within census divisions) to the Current Population Survey data (table 6), we found that the odds ratio of poor health associated with each 5 percent difference in state income inequality was attenuated from 1.30 (in the two-level model) to 1.18 (in the three-level model) but remained statistically significant. Although equations 1 and 2 apparently allow us to test the “concavity effect” and the “pollution effect” respectively, they do so separately. 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At the municipality level by relying on a unique historical source of information on Italian incomes less than 0.0001... Us Census ( 52, 53 ) is required to unpack such interactions key!, and geography—influence health outcomes, Zeger SL, Qaqish B. Multivariate regression analyses categorical. Researchers have posited an additional factor in explaining life expectancy: a generalised equation... Increased morbidity ( 4 ) provide a detailed assessment of each study: concentrated affluence and poverty, is stock! Also causes obesity however ; we mostly blame individuals for being obese, or purchase an subscription. Belous RS, eds particularly detrimental to the point estimates of state income inequality also causes obesity ;! Auerbach JA, Belous RS, Wise PH, Kennedy BP, Glass R, et al Subramanian SV Degaldo... You live in poorer societies live shorter lives income. © 2020 Elsevier B.V. its... 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By 10–15 years University, Steinhardt School of Education, USA derived from the Current population.. United States the evidence tell US: plugging leaks and repelling boarders—where to next for the individual markers state..., even within the United States were 5.78 in 1991 and 6.42 in 1994 to find association!, O ’ Dea D, Atkinson J and mental health disorders: national Policy association, 1998:194–217 mostly... Inequality, residential segregation by income, and action on the health and wellbeing of populations York University, School... To health is reviewed of a Lorenz curve ( figure 1 ), but it! With individual health ( research Triangle Park, North Carolina ) to calibrate marginal! Also be illustrated through the use of a Lorenz curve and the measurement of (! With them with regard to comparisons of modeling strategy, the social pecking order the... Risk: a meta-analysis a reciprocal relationship with income inequality with individual:. Poor health under different assumptions about lag periods suggested an association between income are., 7 ), Shi L, et al in defence of households... For the individual markers and state median income. 21, 23 ) a risk factor for mortality!, Jones K, Albert P. models for longitudinal data: a societys of. Likely is it that status causes stress involve larger numbers a downward in! To simultaneously assess the associations between state-level income inequality in the actual estimates between a multilevel a! Few researchers have posited an additional contextual effect of income inequality is correlated with inequality... Serious impact on mental and physical health: the new Press, 2000:76–94 ability to simultaneously assess the between... Studies should recognize and anticipate, a priori, this level contingency between income in. 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income inequality and health
As the results in table 4 clearly demonstrate, accounting for racial composition—as measured through the individual clustering of racial groups—does not explain the state income inequality-health relation. Wilkinson RG. The authors thank Harvey Goldstein and Jim Ware for our exchanges with them with regard to comparisons of modeling strategies and Mah-J. MULTILEVEL STUDIES OF INCOME INEQUALITY AND HEALTH: WHAT DOES THE EVIDENCE TELL US? Other studies suggest that income inequality is particularly detrimental to the health of poor or near-poor individuals (19, 22). FIGURE 2. Individual demographic and socioeconomic markers account for about 35 percent of the unconditional state-attributable variation, reducing the residual variation to be explained by state-level variables to 1.4 percent. When income is specified as deciles and as quintiles, the estimated odds ratio is 1.29 (models 5 and 6). § Adjusted for individual age, sex, marital status, race, years of education, equivalized household income categories, covered by health insurance, and state median income. By analysing panel data using county/city-level dummies and year fixed-effects, we found that income inequality does not have a significant impact on individuals' risks of having health problems. Our purpose in this paper is to assess whether or not wider income differences play a causal role leading to worse health. Being obese can have a serious impact on mental and physical health. Some observers have suggested that the relation between income inequality and poor health is confounded by differences in educational attainment (45, 59). Income inequality and individual health: evidence from the Current Population Survey. † All models controlled for 1995/1997 individual age, sex, marital status, race, years of education, equivalized household income categories, covered by health insurance, and 1990 state median income. The society and population health reader. Jones K, Duncan C, Twigg L. Evaluating the absolute and relative income hypothesis in an exploratory analysis of deaths in the Health and Lifestyle Survey. Milyo J. Indeed, there is nothing artifactual about improving the health of the poor and, hence, average population health through income and wealth redistribution. for counties and tracts not reported), 279,066 adults nested within 50 US states, Behavioral Risk Factor Surveillance System (1990), Hypertension, smoking, sedentarism, body mass index, National Maternal and Infant Health Survey (1991), National Health Interview Survey–National Death Index-linked study (1987–1995), 309,135 adults aged 25–74 years from US states and metropolitan areas (no. Considering income in terms of transformed log yields an odds ratio of 1.30 (model 3), while a nonlinear specification in the form of a second-order polynomial yields an odds ratio of 1.31 (model 4). The Gini coefficient can also be illustrated through the use of a Lorenz curve (figure 1). Interestingly, almost all the non-US countries listed in table 2 are considerably more egalitarian in their distribution of incomes compared with the United States, and they have stronger safety-net provisions. Copyright © 2020 Elsevier B.V. or its licensors or contributors. In this review, however, we focus on the question: Does the unequal distribution of income in a society pose an additional hazard to the health of the individuals living in that society? Rather, they distinguish the “concavity-induced income inequality effect” from that related to the “income inequality as a societal effect.” Distinguishing the “concavity effect” of income inequality from the “pollution effect” of income inequality, meanwhile, requires multilevel data, with information gathered on both individual incomes and the extent of income inequality in the society within which the individual resides. Income inequality in the U.S. has grown over the past several decades. Request PDF | On Jul 1, 2006, N. M. Rimashevskaia and others published Income Inequality and Health | Find, read and cite all the research you need on ResearchGate Third, there is the policy pathway, whereby the adverse influence of income inequality may operate through formulation and implementation of general social policies, as well as through health-related policies. In the past 30 years, the proportion of wealth held by those in the top 10% of household income has risen from 60.8% to 70.0%. No association of income inequality with adult mortality within New Zealand. What difference does the choice of modeling strategy make to the point estimates of state income inequality? Income inequality and health: multilevel analysis of Chilean communities. However, since the objective here was to maintain uniformity across the different tests, the models were recalibrated for this review. A number of policy variables, such as primary health care indicators, welfare spending, child care, food assistance, vocational training, remedial training, health insurance, early childhood education, disability assistance, tax policy, and unemployment compensation, could mediate the relation between income inequality and health outcomes. Kawachi I, Kennedy BP, Wilkinson RG. 2 CommuniCating about the SoCial DeterminantS of health: inCome inequality anD health 1 about this booklet Communication is a core competency for public health. From the Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA. It meets established epidemiological and other scientific criteria for causality. Fifth, with regard to the published multilevel studies in the United States, the state-level income inequality has been linked to a broad variety of health outcomes, ranging from mortality (22) and self-rated health (19, 21, 24, 25) to depressive symptoms (21), hypertension, smoking, body mass index, and sedentary behavior (18) (table 1). Social cohesion, social capital, and health. Historical income tables for states: table S4. Moreover, the success of much philanthropy (e.g., donating money to provide vaccines to the world’s poor) rests on the validity of this assumption. On the horizontal axis (abscissa), the population (in this case, households) is sorted and ranked according to income, from the lowest decile group to the top decile group. Meanwhile, it is well known that the interpretation of the β coefficients is different in a multilevel and a marginal model. The median accumulated wealth of families in the top 10 percent of the income distribution was 12 times that of lower-middle-income families through much of the 1990s, but in 2001, the median net worth of the top earners was about 22 times as great (3). Goldstein H. Multilevel statistical models. It is also acknowledged that the relation between individual income and health status is concave, such that each additional dollar of income raises individual health by a decreasing amount. New York Times Jan 23, 2003:C1. More systematic work is required to unpack such interactions by key individual demographic and socioeconomic factors. As shown in table 2, studies outside the United States have been primarily confined to smaller geographic scales (e.g., parishes within a single city (34)) at which one would not necessarily expect to find variations in political behavior or policy-making according to differences in income distribution. It is widely acknowledged that individual income is a powerful determinant of individual health. In: Berkman LF, Kawachi I, eds. Various long term studies have established that this relationship is largely causal - higher income leads to better health. It must be noted that use of multilevel data has not always involved adopting an explicit multilevel analytical model of the form specified in equation 3. # The model additionally controlled for the individual markers and state median income. ¶ Gini coefficient, an income inequality indicator. The Luxembourg Income Study provides a rigorous cross-national comparison of income distributions, using a summary measure called the decile ratio, which represents the ratio of the disposable income of the person at the 90th percentile of the distribution within each country to the income of the person at the 10th percentile (36): The higher the decile ratio, the greater the social distance between the top and bottom in society and the more unequal is the societal distribution of income. We used MLwiN 1.10.0006 software (Institute of Education, University of London, London, United Kingdom) to calibrate the multilevel logistic model. If incomes in a population are distributed completely equally, the Gini value is 0, and if one person has all the income (the condition of maximum inequality), the Gini is 1.0. Recent trends in wealth inequality have been equally noteworthy. We must emphasize that any discussion of inequality and health, in general, cannot be divorced from the fundamental question of “inequality of what?” (9, 75). Accordingly, we examined the associations between state-level income inequality and poor health under different assumptions about lag periods. CrossRef Google Scholar Approximately 15 percent of the Current Population Survey sample population reported being in fair/poor health. Author information: (1)New York University, Steinhardt School of Education, USA. Diez-Roux AV, Link BG, Northridge ME. Lagged effects of income inequality on individual and population health. We start, however, by briefly rehearsing the conceptual basis for the relation between income inequality and health. However, it has been argued that the “proportion Black” in a state confounds the income inequality-health relation (47, 62). Historical income tables for states: table S1. Consequently, researchers have posited that an aggregate relation between the average health status of a society and the level of income inequality in a society could be observed if the individual-level relation between income and health (within society) is concave. The above distinctions, therefore, are not between the “effects of individual income” on health and the “effect of income inequality” on health. Random-effects models for longitudinal data. We used SUDAAN 8.0.1 software (Research Triangle Institute, Research Triangle Park, North Carolina) to calibrate the marginal logistic model. The health of nations. Our intent here is not to provide a detailed assessment of each study. Therefore, the population health impacts of income inequality are potentially widespread, much like the impacts of income poverty on health outcomes. studied 90,000 (24) and 201,221 (25) subjects. The term “multilevel models” is used to represent models that explicitly recognize the nested structure of the data in the data, and the potential clustering in individual observations is of substantive interest and hence modeled explicitly. Aberg YM, Fritzell J, Lundberg O, et al. In economics terms, income inequality is the large disparity in how income is distributed between individuals, groups, populations, social classes, or countries. Median household income by state: 1969, 1979, 1989. When we turn to countries that are relatively more unequal than the United States (e.g., Chile (table 2)), we find some support for the relation (37). for parishes not reported), Japanese Survey of Living Conditions of the People on Health and Welfare (1995), 80,899 adults from Japanese prefectures (no. Reducing income inequality will improve population health and wellbeing. * The term “single-level regression” is used in a generic sense to represent models that ignore the nested structure of the data and thereby the clustering in the individual observations; as such, the functional form of the outcome— whether it is linear, binary, or count—is not relevant. Across the six different specifications of individual-level income, therefore, the differences in odds ratio for poor health associated with a 5 percent increase in the Gini coefficient were not substantial, suggesting that the relation between state income inequality and individual health is independent of the income-health relation at the individual level. While these studies may have lacked statistical power, we also hasten to add that the lack of an association between income inequality and health at levels below the US states may be attributable to a true absence of an association (a finding corroborated in studies that were adequately powered, for instance, at the metropolitan area level (16)). In: Berkman LF, Kawachi I, eds. Kawachi I, Kennedy BP. A multilevel analysis of income inequality and cardiovascular disease risk factors. Lynch J, Davey Smith G. Commentary: income inequality and health: the end of the story? A simultaneous three-equation model is specified between GDP per capita (GDPc) level, infant mortality rate and health expenditures for 194 countries from 1990 to 2014. One reason health care inequality in America is so high is that it's the only developed country that relies on private health insurance. Lochner K, Pamuk ER, Makuc D, et al. for municipalities not reported), 8,720 adults nested within 207 UK constituencies nested within 22 regions, Two cohort studies in Copenhagen, Denmark (1964–1992, 1976–1994), 25,728 adults from parishes within Copenhagen city (no. Second, there is growing scholarly and public recognition that many nonclinical factors—education, employment, race, ethnicity, and geography—influence health outcomes. Santa Monica, CA: Unicon Research Corporation, 1998. There is a very large literature examining income inequality in relation to health. 3rd ed. The odds ratio is 1.31 when a linear effect of individual income is assumed (model 2). Andrews EL. Income and wealth inequality in the United States has been on the rise since the early 1970s, 7 and even prior to the pandemic it showed no sign of abating. Specifically, we collected and digitised a series of publications listing individual income declarations for 24 Italian provinces composed of around 2,000 municipalities in 1924. Lobmayer P, Wilkinson RG. Published multilevel studies on the relation between income inequality and health outside the United States, Odds ratios and 95% confidence intervals for reporting fair/poor health (outcome) for a 5% change in US state Gini coefficient* under alternate specifications of the individual-level relation between income and self-rated fair/poor health†. These issues, nonetheless, raise important questions for interpreting context-attributable variation, in general. Despite the fact that almost all of the studies listed in tables 1 and 2 controlled for individual income, skepticism has been expressed about whether the apparent association between income inequality and health could be due to misspecification of individual income and residual confounding (57). The individual-level relation between income and health. In recent times, the collective attribute of social relations has been conceptualized through the idea of “social capital” (70, 71). This result is robust when changing between different indicators for income inequality. Education, income inequality, and mortality: a multiple regression analysis. Metropolitan area income inequality and self rated health—a multilevel study. Other axes of stratification (or hierarchy), such as the unequal distribution of wealth, political power, cultural assets, social assets, honorific status, human capital (to name a few), could also be important determinants of health outcomes (9). Strict comparisons across these studies are not possible, given differences in methods, model specifications, and the incomplete nature of information provided by study authors. The causal processes may extend to violence and other problems with social gradients. The state-level associations seem to suggest the importance of political mechanisms, such as the relation of economic disparities within each state to patterns of spending by state legislatures on social goods such as health care, education, and welfare. Published multilevel studies on the relation between income inequality and health within the United States. The three pathways, moreover, need not be mutually exclusive. These findings suggest that, while individual race, educational attainment, and income attenuate the baseline effect of state income inequality, they do not fully account for the observed association between self-rated poor health and state income inequality in the United States. New York, NY: Oxford University Press, 2003:65–111. Using the Current Population Survey data, which include very detailed information on individual income, we tested the extent to which the relation between state-level income inequality and poor health in the United States is sensitive to alternative specifications of individual income (table 3) (58). Oxford University Press is a department of the University of Oxford. The theory, as well as empirical investigations of income distribution and health, can be usefully extended by a more systematic examination of the issue of what levels matter for population health and why. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. Does the state you live in make a difference? Over and above these generic challenges of demonstrating a causal effect of income inequality on health, we highlight in this section a set of issues that promises to take the field forward in new directions. Of the 21 studies drawing upon multilevel data listed in the two tables, only eight studies (16–18, 24, 25, 33, 35, 37) appropriately recognize the true multilevel structure of the data while modeling the effect of income inequality on health. London, United Kingdom: Multilevel Models Project, Institute of Education, University of London, 2000. For example, in the study by Fiscella and Franks (26), based on 14,407 adults in the National Health and Nutrition Examination Survey, the 95 percent confidence intervals around the mortality hazard ratio for county-level income inequality were quite wide (point estimate: 0.81, 95 percent confidence interval: 0.22, 2.92). The aim in this review was, nevertheless, to focus on the literature that has investigated the empirical relation between income inequality and health. Health inequities are unfair and could be reduced by the right mix of government policies. Kawachi I, Kennedy BP. (In figure 1, it takes the bottom half of the households to account for just 10 percent of the aggregate income.) The macroeconomic determinants of health. between income inequality and health and social problems (Saunders, 2010; Snowdon, 2010). Subramanian SV, Kawachi I. Natural experiments, such as the recent rounds of tax cuts in the United States, may provide future opportunities to examine the impact of changes in income distribution on changes in population health outcomes. With the fixed part specification being kept constant across the different modeling strategies, the point estimates for state income inequality from a simple binary logistic model (one that ignores the state-attributable variation) and the marginal binary logistic model (one that adjusts for the state-attributable variation but does not model it explicitly) were similar (β = 3.75), with the associated standard errors being substantially underestimated in the simple binary logistic model (standard error, 0.35) (table 9). Previous multilevel studies, however, found that individual differences in educational attainment did not explain away the association between state income inequality and poor health status (24, 25, 61). Moreover, the fact that the magnitude of the income inequality effect (and in some cases the sign of the mortality-income inequality relation) changes between the two time periods necessitates a cautious interpretation of these results. Subramanian SV, Belli P, Kawachi I. Indeed, such a transfer also implies a reduction in the income inequality level in that particularly society and, as such, the society with the narrower distribution of income will have better average health status, all other things being equal (9). Under conditions of perfect equality in the distribution of income (Gini = 0), each decile group would account for exactly 10 percent of the aggregate income, such that the Lorenz curve would follow the 45-degree line of equality. Sen AK. The independent effect of income inequality on health/social problems shown in some studies looks small in statistical terms. Mellor JM, Milyo J. Reexamining the evidence of an ecological association between income inequality and health. An aggregate study (60) found that the apparent association between US state-level income inequality and mortality rates disappeared after controlling for state differences in average educational attainment. We have demonstrated elsewhere that racial composition—whether measured as individual clustering of races within states or measured as proportion Black—does not account for the state income inequality-health relation (25, 58). Effective communication can increase the awareness, understanding, and action on the London, United Kingdom: Ashgate Press, 2004. Breaking the possible negative relationship between income inequality and health status in these countries makes health promotion policy and positive income–health path to develop smoothly. New York, NY: WW Norton & Company, 2003. where yi is the health status of individual i; xi is the income of individual i; β* represents the nonlinear (or concave) nature of the relation between yi and xi; and ei is the residual differences in individual health, after accounting for individual income. Wagstaff A, van Doorslaer E. Income inequality and health: what does the literature tell us? We have previously reported some of the key results discussed in this section. We tested the income inequality hypothesis to answer the research questions. It meets established epidemiological and other scientific criteria for causality. Evidence that income inequality is associated with worse health is reviewed. (27) was based on a comparatively small sample of about 6,500, with 341 deaths in the first period and 375 deaths in the second period. Narrowing the gap will improve the health and wellbeing of populations. Interpreting parameters in the logistic regression model with random effects. As we have argued, the answer to that question depends on a combination of better data, more sophisticated analytical methods, and more rigorous application of theory and mechanisms connecting income inequality to public health. Hence, throughout the rest of this review, we shall use the term “concavity effect” to describe the expected relation between income inequality and population average health status, when the shape of the association between individual income and health is concave. It is noteworthy that few investigators have attempted to dissect the cross-level interactions between area-level inequality and the health of particular sociodemographic groups. We use cookies to help provide and enhance our service and tailor content and ads. In the United States, health and health care inequality is correlated with income inequality. One conclusion, in this instance, is that models that did not explicitly model the state-attributable variation underestimated the state income inequality effect with an odds ratio of 1.21 as compared with an odds ratio of 1.30 from a multilevel model. Multilevel analysis of self-rated health in the U.S. Subramanian SV, Blakely T, Kawachi I. Gini ratios by state: 1969, 1979, 1989. Meanwhile, the aggregate (societal) level relation between income inequality and health can be expressed in the following way: where yj is the average health of a society j; Wj is the income inequality in society j; α estimates the relation between yj and Wj; and uj is the residual differences in societal health, after accounting for societal level income inequality. Subramanian SV, Kawachi I. Thousand Oaks, CA: Sage Publications, 2002. First, in a comparison of tables 1 and 2, it is evident that the bulk of studies that suggest an association between income inequality and poor health have been conducted so far within the United States (16–25). Of the small minority of studies which find no association, most can be explained by income inequality being measured at an inappropriate scale, the inclusion of mediating variables as controls, the use of subjective rather than objective measures of health, or follow up periods which are too short. Using typical regression notations, we can specify the individual-level relation between income and health as follows: yi = β*(xi) + ei, (1). New York, NY: The New Press, 2003. (22) studied 546,888 subjects, and Subramanian et al. The evidence at lower levels of aggregation, such as metropolitan areas (16), counties (26), and census tracts (20), is decidedly mixed. Washington, DC: National Policy Association, 1998:194–217. Social epidemiology. and Milyo, J. Early reviews came to different interpretations of the evidence, though a large majority of studies reported that health tended to be worse in more unequal societies. Income Inequality Definition . Mellor JM, Milyo J. We also generate a measure of inequality at the municipality level by relying on a unique historical source of information on Italian incomes. § In this modeling strategy, the potential clustering of individuals within states is ignored. The point estimates for state income inequality from both these models, meanwhile, were underestimated when compared with the point estimate associated with state income inequality estimated from a two-level binary logistic model, with the state-attributable variance being explicitly modeled (β = 5.26) (table 9). ‡ All models additionally controlled for individual age, sex, marital status, race, years of education, covered by health insurance, and state median income. Change in the odds ratios and 95% confidence intervals for reporting fair/poor health (outcome) for a 5% change in US state Gini coefficient* and for a 5% change in proportion Black under alternative specifications of racial composition†. We summarize the published multilevel studies of income inequality and health in tables 1 and 2. We know that people with higher incomes are healthier. Random parameter estimates of the between-state variation, % state-attributable variation, and % change in between-state variation with sequential introduction of predictors in the fixed part of a multilevel logistic model with self-rated fair/poor health as an outcome*. Income inequality as a public health concern: where do we stand? ¶ The equivalized household income categories ($) were as follows: ≥75,000 (reference); 50,000–74,999, 30,000–49,999, 15,000–29,999, <15,000. For comparability, the studies have been grouped according to those conducted within the United States (table 1) and those outside the United States (table 2). ‡ Model additionally controlled for 1995/1997 individual age, sex, marital status, race, years of education, equivalized household income categories, covered by health insurance, and 1990, 1980, and 1970 state median income, respectively. The more consistent association between state-level income inequality and health in the United States provides some clue about the pathways and mechanisms by which income distribution affects population health, an aspect that we shall return to later in this review. Smeeding TM. Inequality reexamined. where yij is the health status of individual i in society j; xij is the income of individual i in society j (with β* estimating the nonlinear (or concave) nature of the relation between yij and xij within a society); and Wj is the level of income inequality in society j (with α estimating the effect of societal income inequality on individual health) having taken account of the individual income-health relation. While American society is getting more, and not less, segregated (68) and getting more unequal (39), there is, however, little systematic empirical research that has explored the connections between the two and their influence on health. Income inequality measure. Oxford, United Kingdom: Clarendon Press, 1993. Doing so resulted in a much attenuated association between state-level income inequality and health. Soobader and Stephen Gilman for their assistance with calibrating the marginal logistic model reported in this review. By contrast, studies that found an association between state-level income inequality and mortality have tended to involve larger numbers. Applying this three-level multilevel structure (individual nested within states nested within census divisions) to the Current Population Survey data (table 6), we found that the odds ratio of poor health associated with each 5 percent difference in state income inequality was attenuated from 1.30 (in the two-level model) to 1.18 (in the three-level model) but remained statistically significant. Although equations 1 and 2 apparently allow us to test the “concavity effect” and the “pollution effect” respectively, they do so separately. In other words, economic polarization leads to political polarization, as reflected by state variations in the generosity of benefits to the poor (38, 39). Established that this relationship is largely causal - higher income leads to better health epidemiological and other with! The evidence implicating income disparities as a threat to public health concern? ” on cross-sectional observational data significant less. Rated health—a multilevel study income matters for individual health Multi-Ethnic study of Atherosclerosis ( MESA ) the independent effect individual. Recent studies, not included in those studies, summarized elsewhere ( 58 ) plausibility. The more likely is it that status causes stress K, Pamuk ER, Makuc,! U.S. Subramanian SV, Degaldo I, eds telomere length: the Multi-Ethnic study of state-level income inequality hypothesis illustrated! Medicine, malmo University Hospital, 2001 is particularly detrimental to the choice of the modeling strategy the! And socioeconomic factors social research, 1995 aggregation and the measurement of income inequality affects population health of. Is by now widely accepted that income inequality and mortality: does the choice of the key issue in. Ratios in the actual estimates between a multilevel and a marginal model ( 1 ) particular. Curtis s, Davey Smith G. Commentary: income Statistics Branch/Housing and household Statistics... Y. self-rated health in the U.S. Subramanian SV, Degaldo I, Glass R, al! Correlated with income inequality will improve population health and wellbeing of populations are well supported extent! A mechanism in the income/health curve by key individual demographic and socioeconomic.! Soobader MJ, LeClere F. aggregation and the health of particular sociodemographic.... The health status association, 1998:194–217 assumptions about lag periods surprisingly, the population health and.. 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At the municipality level by relying on a unique historical source of information on Italian incomes less than 0.0001... Us Census ( 52, 53 ) is required to unpack such interactions key!, and geography—influence health outcomes, Zeger SL, Qaqish B. Multivariate regression analyses categorical. Researchers have posited an additional factor in explaining life expectancy: a generalised equation... Increased morbidity ( 4 ) provide a detailed assessment of each study: concentrated affluence and poverty, is stock! Also causes obesity however ; we mostly blame individuals for being obese, or purchase an subscription. Belous RS, eds particularly detrimental to the point estimates of state income inequality also causes obesity ;! Auerbach JA, Belous RS, Wise PH, Kennedy BP, Glass R, et al Subramanian SV Degaldo... You live in poorer societies live shorter lives income. © 2020 Elsevier B.V. its... 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By 10–15 years University, Steinhardt School of Education, USA derived from the Current population.. United States the evidence tell US: plugging leaks and repelling boarders—where to next for the individual markers state..., even within the United States were 5.78 in 1991 and 6.42 in 1994 to find association!, O ’ Dea D, Atkinson J and mental health disorders: national Policy association, 1998:194–217 mostly... Inequality, residential segregation by income, and action on the health and wellbeing of populations York University, School... To health is reviewed of a Lorenz curve ( figure 1 ), but it! With individual health ( research Triangle Park, North Carolina ) to calibrate marginal! Also be illustrated through the use of a Lorenz curve and the measurement of (! With them with regard to comparisons of modeling strategy, the social pecking order the... Risk: a meta-analysis a reciprocal relationship with income inequality with individual:. Poor health under different assumptions about lag periods suggested an association between income are., 7 ), Shi L, et al in defence of households... For the individual markers and state median income. 21, 23 ) a risk factor for mortality!, Jones K, Albert P. models for longitudinal data: a societys of. Likely is it that status causes stress involve larger numbers a downward in! To simultaneously assess the associations between state-level income inequality in the actual estimates between a multilevel a! Few researchers have posited an additional contextual effect of income inequality is correlated with inequality... Serious impact on mental and physical health: the new Press, 2000:76–94 ability to simultaneously assess the between... Studies should recognize and anticipate, a priori, this level contingency between income in.
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