For whom is income inequality most harmful? A multi-level analysis of income inequality and mortality in Norway

This study investigates the degree to which contextual income inequality in economic regions in Norway affected mortality during the 1990s, above the effects of mean regional income and individual-level confounders. A further objective is to explore whether income inequality effects on mortality differed between socioeconomic groups. Data were constructed by linkages of administrative registers encompassing all Norwegian inhabitants. The outcome variable was all-cause mortality during 6 years (i.e., died 1994-1999 or alive end of 1999). Men and women aged 25-66 in 1993 were analysed. Regions' mean income and income inequality (in terms of gini coefficients) were calculated from consumption-units-adjusted family disposable income. Individual-level variables included sex, age, marital status, individual income, education, and being a recipient of health-related welfare benefits. Multilevel logistic regression models were fitted for 2,197,231 individuals nested within 88 regions. After adjusting for regional mean income and individual-level variables, the odds ratio (OR) for mortality 1994-1999 was 1.028 (95% CI 1.023-1.033) on the gini variable multiplied by 100. Analyses of cross-level interactions indicated some, albeit modest, income inequality effects on mortality in the upper income and educational categories. Among those with low individual income, low education, and among recipients of health-related welfare benefits, mortality effects of higher regional income inequality were significantly stronger than among those more advantageously placed in the social structure. The results of this study differ from previous studies which have suggested that contextual income inequality has a minor impact on population health in egalitarian countries. The results indicate that in Norway, neither a comparatively egalitarian income distribution nor generous and comprehensive welfare institutions hindered the emergence of regional-level income inequality effects on mortality, and these effects were particularly marked among socioeconomically disadvantaged groups. Explanations for the results are discussed.     

Should we worry about income inequality?

Liberals (in the European sense) argue that a liberal free-market economic policy regime-nationally and globally-is good for economic growth and poverty reduction and for keeping income inequality within tolerable limits. Second, they argue that substantial income inequality is desirable because of its good effects on other things, notably incentives, innovation, and panache; and conversely, they dismiss concerns about growing inequality as "the politics of envy." Third, they argue that the core liberal theory of capitalist political economy satisfactorily explains the central tendencies in the role of the state in advanced capitalist economies. This essay challenges all three arguments on both conceptual and empirical grounds. It then suggests why the arguments are nevertheless widely accepted, proposes criteria for deciding how much inequality is fair, and ends by suggesting ways for achieving higher salience for income redistribution (downwards) in political agendas.     

Physician labor supply: do income effects matter?

This paper estimates a model of physician labor supply, focusing on the impacts of wage and non-wage income. We find evidence of significant income effects. For male physicians, the income effect of a wage change on labor supply is negative, with an elasticity of -0.26. The pure substitution effect of a wage change increases labor supply: a 1% increase in wages leads to a 0.49% increase in labor supply, controlling for income effects. The results also suggest that the labor supply decisions of females are more responsive to variations in their earnings than are those of males.     

Does the earned income tax credit increase children's weight? The impact of policy‐driven income on childhood obesity

I exploit substantial increases in the earned income tax credit to study how a policy‐driven change in family income affects childhood obesity. Using the National Longitudinal Survey of Youth 1979, my difference‐in‐differences estimates indicate that the probability of being obese increased by 3 percentage points among children whose families experienced a greater income shock. A further investigation suggests that a reduction in maternal time with children played a greater role in children's weight gain than income. The paper's finding shows that a program that is not designed for health purposes, such as earned income tax credit, can have unintended effects on health outcomes.     

Higher income and uninsured: common or rare?

Massachusetts plans to penalize those who do not have health insurance, targeting higher-income people. Are higher-income Americans a small or substantial share of the uninsured? The U.S. Census Bureau reports that one in three Americans without health insurance lived in a household with income greater than $50,000 in 2005. Many of these higher-income uninsured people do not fit the profile of free-riders who have the money but are unwilling to buy coverage. A majority have lower incomes but live with others; only together are they higher income. For others, higher income or lack of insurance is transient.     

Attitudes of low‐income clinic patients toward menopause

The bulk of menopause research has been conducted on samples of middle‐class White women. In this study, attitudes toward menopause in a sample of 66 low‐income women at a women's clinic were studied using Bowles's (1986) Menopause Attitude Scale (MAS) and the attitude segment of Millette's (1981) survey of attitudes and knowledge about menopause. The typical participant was a single, 34‐year‐old Black woman with a yearly income below $10,000. Research questions examined general attitudes toward menopause, and MAS scores of Bowles's middle‐income, White sample were compared with those of the present low‐income, predominantly Black sample. Results indicated a somewhat positive attitude toward menopause in the low‐income sample. Although the trend was toward higher scores in the low‐income group, only the 18‐ to 25‐year‐olds in the low‐income group had significandy higher MAS scores man the corresponding age group in Bowles's sample. Nursing implications pertain to teaching and support group leadership.     

Different dental care setting: does income matter?

In this paper we consider the use of mobile dental clinics as a means of improving access to dental care among primary school children in Southern Thailand by reducing the opportunity cost of service use to parents. Parents' willingness to pay (WTP) is measured for three different services provided in a community hospital dental clinic and a school-based mobile clinic. Although the service setting does not affect significantly the WTP for treatment directly, the estimated positive association between WTP and income is modified by setting. The results indicate that the potential for mobile clinics to increase utilization of services among primary school children is associated with parents' income, with the difference in valuation of dental services between the two settings being less among lower income parents than higher income parents. However, even among lower income parents our results indicate that the potential for increasing service utilization among children depends on the improvements in access associated with the mobile clinic not being achieved at the opportunity cost of lower levels of effectiveness.     

Do individuals consider expected income when valuing health states?

OBJECTIVES: The purpose of this study was to empirically explore whether individuals take their expected income into consideration when directly valuing predefined health states. This was intended to help determine how to handle productivity costs due to morbidity in a cost-effectiveness analysis. METHODS: Two hundred students each valued four hypothetical health states by using time trade-off (TTO) and a visual analogue scale (VAS). The students were randomly assigned to two groups. One group was simply asked, without mentioning income, to value the different health states (the non-income group). The other group was explicitly asked to consider their expected income in relation to the health states in their valuations (the income group). RESULTS: For health states that are usually assumed to have a large effect on income, the valuations made by the income group seemed to be lower than the valuations made by the non-income group. Among the students in the non-income group, 96 percent stated that they had not thought about their expected income when they valued the health states. In the income group, 40 percent believed that their expected income had affected their valuations of the health states. CONCLUSION: The results show that, as long as income is not mentioned, most individuals do not seem to consider their expected income when they value health states. This indicates that productivity costs due to morbidity are not captured within individuals' health state valuations. These findings, therefore, suggest that productivity costs due to morbidity should be included as a cost in cost-effectiveness analyses.     

Is income relevant for health expenditure and economic growth nexus?

This paper examines the relationship between health expenditure and economic growth using panel data consisting low and high-income countries. Using dynamic panel data methodology, we analyze twenty five high-income and nineteen low-income economies for the periods of 1995–2012 and 1997–2009, respectively. We find reciprocal relationship between health expenditure and economic growth in the short run and one-way causality from economic growth to public health expenditure in the long-run. In high-income countries, there is a two-way causality for both private and public health expenditures in the short-run, while in the long-run there is a one-way causality between economic growth and private health expenditures. The crucial finding of this study is that private health expenditures have negative influence on economic growth while public health expenditures have both negative and statistically significant effect.     

Do people die from income inequality of a decade ago?

The long-term impact of income inequality on health has not been fully explored in the current literature. Until now, 4 studies have examined the lagged effect on population/group mortality rate at the aggregate level, and 7 studies have investigated the effect of income inequality on subsequent individual mortality risk within a restricted time period. These 11 studies suffer from the same limitation: they do not simultaneously control for a series of preceding income inequalities. The results of these studies are also mixed. Using the U.S. National Health Interview Survey data 1986-2004 with mortality follow-up data 1986-2006 (n = 701,179), this study investigates the lagged effects of national-level income inequality on individual mortality risk. These effects are tested by using a discrete-time hazard model where contemporaneous and preceding income inequalities are treated as time-varying person-specific covariates, which then track a series of income inequalities that a respondent faces from the survey year until s/he dies or is censored. Findings suggest that income inequality did not have an instantaneous detrimental effect on individual mortality risk, but began exerting its influence 5 years later. This effect peaked at 7 years, and then diminished after 12 years. This pattern generally held for three measures of income inequality: the Gini coefficient, the Atkinson index, and the Theil entropy index. The findings suggest that income inequality has a long-term detrimental impact on individual mortality risk. This study also explains discrepancies in the existant literature.     

Education and income: which is more important for mental health?

STUDY OBJECTIVE: To assess which indicators of socioeconomic status are associated with an increased prevalence of common mental disorders. DESIGN: Cross sectional household survey. SETTING: Santiago, Chile. PARTICIPANTS: Random sample of adults aged 16-65 residing in private households. Main results: Less education (odds ratio 2.44, 95% confidence intervals 1.50 to 3.97), a recent income decrease (odds ratio 2.14, 1.70 to 2.70), and poor housing (odds ratio 1.53, 1.05 to 2.23), were the only socioeconomic status variables that remained significantly associated with an increased prevalence of common mental disorders after adjustments. The prevalence of common mental disorders was also higher among people with manual unskilled occupations, overcrowded housing, and lower per capita income but these associations disappeared after adjustment for other explanatory and confounding variables. CONCLUSIONS: There is a strong, inverse, and independent association between education and common mental disorders. However, income was not associated with the prevalence of common mental disorders, after adjusting for other socioeconomic variables. Similar results have been found in other Latin American studies but British studies tend to find the opposite, that income but not education is associated with common mental disorders. Understanding the impact of socioeconomic factors on mental health requires research in poor as well as rich countries.     

Can we defeat meningococcal disease in low and middle income countries?

The development of multivalent conjugate and protein-based meningococcal vaccines may make global control of meningococcal disease possible. However, achieving control of meningococcal disease in low and middle income countries will be challenging. In low income countries whose vaccination programmes receive financial support from the Global Alliance for Vaccination and Immunisation, the main challenge is lack of sufficient epidemiological information to allow rational decisions on vaccine introduction to be made and, in these countries, enhanced surveillance is needed. In middle income countries, financial challenges predominate. These could be met by demonstration of the cost effectiveness of new meningococcal vaccines and through the introduction of a tiered-pricing system.     

Does income inequality modify the association between air pollution and health?

BACKGROUND: It has been hypothesized that socioeconomic status may act as an effect modifier of the association between air pollution and health. In this study, we investigated whether income inequality may modify the association between fine particulate pollution and self-reported health. METHODS: We combined several different sources of data. Demographic and socio-economic data, at the individual level, were drawn from the 2001 US Behavioral Risk Factor Surveillance System (BRFSS). County-level particulate pollution data for the year 2001 were provided by the US Environmental Protection Agency. State-level income inequality was measured by the Gini index using US census data from the year 2000. We used a hierarchical logistic regression to model the association between general self-reported health and fine particulate pollution accounting for income inequality as an effect modifier and controlling for the usual confounders. RESULTS: We found that when income inequality is low (10th percentile of the Gini distribution), the odds of reporting fair or poor health for a 10microg/m3 increase in particulate pollution is 1.34 (95% confidence interval 1.21-1.48). The analogous odds ratio for higher income inequality (60th percentile of the Gini distribution) is 1.11 (95% confidence interval 1.06-1.16). CONCLUSIONS: Income inequality was found to be an effect modifier of the association between general self-reported health and particulate pollution. However, these findings challenged our hypothesis that people living in higher income inequality areas are more vulnerable to the impact of air pollution. We discuss the factors driving these results.     

Does the disbursement of income increase psychiatric emergencies involving drugs and alcohol?

OBJECTIVE: To determine if the incidence of psychiatric emergencies involving drugs or alcohol supports the argument that mentally ill persons contribute to elevated mortality during the days following disbursement of private earnings and public income transfers. STUDY DESIGN: Interrupted time-series using Box-Jenkins methods. DATA COLLECTION/EXTRACTION METHODS: Daily counts of adults admitted to psychiatric emergency services in San Francisco after using drugs or alcohol were derived from medical records for the period January 1 through June 30, 1997. PRINCIPAL FINDINGS: Psychiatric emergencies among males who had used drugs or alcohol were elevated in the early days of the month. Such emergencies among females were not similarly elevated. Emergencies among females who had not used drugs or alcohol were elevated in the early days of the month. CONCLUSION: Elevated mortality in the first week of the month may be attributable, in part, to the "check effect" or use of drugs and alcohol by mentally ill males in the days after they receive income. The contribution of women is more complex and may be induced by drug or alcohol abuse among persons in their social networks. The check effect suggests that persons with a history of substance abuse and mental illness should be offered the opportunity to have their income managed by someone who can monitor and influence how the money is being spent. The fact that drug- or alcohol-related admissions among males exhibit temporal patterns suggests that the provision of preventive as well as treatment services may be strategically scheduled.