Thesis
Reference
Public policy, health care and health outcomes of the poor in advanced democracies
KRIEGER, Ralph
Abstract
In advanced democracies, poverty is an enduring reality. Welfare states are dedicated to fighting poverty. This fight indirectly improves public health by reducing material hardship and social exclusion. Health care systems provide access to health care. My thesis disentangles for the first time the effects of two major social determinants of health, public policy and health care, on the self-rated health status of the poor.
KRIEGER, Ralph. Public policy, health care and health outcomes of the poor in advanced democracies. Thèse de doctorat : Univ. Genève, 2019, no. SdS 116
DOI : 10.13097/archive-ouverte/unige:120768 URN : urn:nbn:ch:unige-1207688
Available at:
http://archive-ouverte.unige.ch/unige:120768
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Public policy, health care and health outcomes of the poor in
advanced democracies
Ralph Krieger
Direction de thèse: professeur Jonas Pontusson
FACULTÉ DES SCIENCES DE LA SOCIÉTÉ
UNIVERSITÉ DE GENÈVE FACULTÉ DES SCIENCES DE LA SOCIETE
Uni Mail
40 bd du Pont-d’Arve CH-1211 Genève 4 SUISSE
www.unige.ch/sciences-societe/
Public policy, health care and health outcomes of the poor in advanced democracies
Ralph Krieger
Thèse 116 – Avril 2019
La Faculté des sciences de la société, sur préavis du jury, a autorisé l’impression de la présente thèse, sans entendre, par-là, émettre aucune opinion sur les propositions qui s’y trouvent énoncées et qui n’engagent que la responsabilité de leur auteur.
Genève, le 17 mai 2019
Le doyen
Bernard DEBARBIEUX
Impression d'après le manuscrit de l'auteur
Table of contents
TABLE OF CONTENTS ... V LIST OF TABLES ... VII LIST OF FIGURES ... IX ABSTRACT ... XI RÉSUMÉ ... XIII ACKNOWLEDGMENTS ... XV
1. INTRODUCTION ... 1
1.1 Literature review: welfare state effects on health inequality ... 8
1.2 The conceptual framework ... 14
1.2.1 Poverty ... 19
1.2.2 Health status ... 24
2. MACRO DATA ANALYSIS OF WELFARE STATES AND HEALTH CARE SYSTEMS ... 29
2.1 Welfare states: conceptual discussion ... 29
2.1.1 Decommodification ... 31
2.1.2 Social welfare generosity ... 34
2.2 Healthcare systems: conceptual discussion ... 36
2.3 Principal component analysis ... 40
2.3.1 Method of principal component analysis ... 40
2.3.2 Health care dimensions ... 41
2.4 Descriptive results ... 44
2.4.1 Social welfare generosity ... 45
2.4.2 Health care systems ... 47
2.4.3 Discussion ... 49
3. MACRO DATA ANALYSIS OF THE EFFECTS OF WELFARE STATES AND HEALTH CARE SYSTEMS ON HEALTH INEQUALITY ... 51
3.1 Hypotheses ... 52
3.2 Methods ... 53
3.3 Data ... 55
3.3.1 Poverty data ... 55
3.3.2 Health data ... 56
3.4 Results ... 57
3.4.1 Descriptive results ... 57
3.4.2 Regression results ... 61
3.5 Discussion ... 65
4. MULTILEVEL ANALYSIS OF THE EFFECTS OF WELFARE STATES AND HEALTH CARE SYSTEMS ON HEALTH INEQUALITY ... 71
4.1 Data and descriptive analysis ... 71
4.1.1 Data ... 71
4.1.2 Descriptive analysis ... 73
4.2 Multilevel logistic regression analysis ... 76
4.2.1 Hypotheses... 76
4.2.2 Methods ... 76
4.2.3 Results ... 79
4.3 Discussion ... 84
5. THE AFFORDABLE CARE ACT IN CALIFORNIA ... 89
5.1 The American health care system ... 91
5.2 Data and descriptive analysis ... 95
5.2.1 Data ... 96
5.2.1 Trends in health care coverage between 2003 and 2016 ... 98
5.2.2 Health insurance in 2015-16 ... 100
5.2.3 Access to health care in 2015-16 ... 101
5.2.1 Trends in the health status of the poor and health inequality between 2003 and 2016 102 5.2.2 Health status of the poor and health inequality in 2015-16 ... 103
5.3 Regression analysis ... 105
5.3.1 Hypotheses... 105
5.3.2 Methods ... 105
5.3.3 Results ... 107
5.3.3.1 Poverty and health insurance effects on access to health care ... 107
5.3.3.2 Poverty and health insurance effects on health status ... 110
5.4 Discussion ... 117
6. CONCLUSION ... 121
APPENDIX ... 127
REFERENCES ... 129
List of Tables
Table 1-1: Federal poverty levels (FPL) and income thresholds (US$) related to public health care programs, 2015 ... 21 Table 1-2: Relative national income levels of the 60% median (US$), 1990, 2000, and 2010 23 Table 1-3: Income levels of the 10th percentile, the 50th percentile and percentile ratio 50/10 ... 24 Table 2-1: The social welfare generosity score, 21 advanced democracies, 1990, 2000 and 2010 ... 36 Table 2-2: Data on health care systems, 21 advanced democracies, 2000 and 2010 ... 39 Table 2-3: Principal components analysis: health care supply dimension and health care institution dimension, 2010 ... 42 Table 2-4: Principal components analysis, component loadings of 21 advanced democracies, 2000 and 2010 ... 44 Table 3-1: Headcount poverty and poverty gap, 1990, 2000, and 2010 ... 58 Table 3-2: Subjective health status of the 1st and 5th income quintile groups (%) and absolute health inequality (percentage points), 21 advanced democracies, 2000 and 2010 ... 60 Table 3-3: Regression results: Social welfare generosity effects on headcount poverty
reduction in 1990, 2000, and 2010 ... 62 Table 3-4: Regression results: Changes in headcount poverty and changes in health
inequality between 2000 and 2010 ... 63 Table 3-5: Regression results: Changes in social welfare generosity, changes in headcount poverty (60% median) and changes in health inequality between 2000 and 2010 ... 64 Table 3-6: Regression results: Trend in health care systems, changes in headcount poverty (60% median) and changes in health inequality between 2000 and 2010 ... 65 Table 4-1: Sample of health status and headcount poverty (60% median), 15 European countries, 2010 ... 73 Table 4-2: Multilevel regression analysis: Social welfare generosity effects on headcount poverty (60% median), 15 European countries, 2010 ... 79 Table 4-3: Multilevel regression analysis: Poverty effects on ill health, 15 European countries, 2010 ... 81 Table 4-4: Multilevel regression analysis: Social welfare generosity and poverty effects on ill health, 15 European countries, 2010 ... 82 Table 4-5: Multilevel regression analysis: Health care supply and poverty effects on ill health, 15 European countries, 2010 ... 84 Table 5-1: Federal poverty levels (FPL) and income thresholds (US$), 2015 ... 98 Table 5-2: Logistic regression analysis: Health care coverage, health plans, and access to health care, California, 2015-16 ... 109 Table 5-3: Logistic regression analysis: Poverty and no access to health care, California, 2009 and 2015-16... 110 Table 5-4: Logistic regression analysis: Health care coverage, health plans and health status, California, 2015-16 ... 113 Table 5-5: Logistic regression analysis: Poverty, health plans and health status, California, 2015-16... 115 Table 5-6: Logistic regression analysis: Poverty and health status, California, 2009 and 2015- 16 ... 116
List of Figures
Figure 1-1: Conceptual framework ... 15 Figure 2-1: Social welfare generosity, 21 advanced democracies, 2010 ... 46 Figure 2-2: Health care supply and health care institution, 21 advanced democracies, 2010 48 Figure 3-1: Changes in the health status of the poor and changes in health inequality, 21 advanced democracies ... 61 Figure 4-1: The health status of the poor and the better off in terms of access to health care services, EU-15 in 2010 ... 75 Figure 5-1: Trend in health insurance schemes, poor adults (18-64 years), California, 2003- 2016 ... 99 Figure 5-2: Type of current health care coverage, male and female adults (18-64 years) by income groups, California, 2015-16 ... 100 Figure 5-3: Access to health care of insured vs. uninsured poor adults (18-64 years),
California, 2015-16 ... 101 Figure 5-4: Trends in health status of poor adults (18-64 years) and health inequality,
California, 2003-2016 ... 103 Figure 5-5: General ill health and disability by income groups, male and female adults (18-64 years), California, 2015-16 ... 104 Figure 5-6: Health conditions by income groups, male and female adults (18-64 years), California, 2015-16 ... 104
Abstract
In advanced democracies, poverty is an enduring reality. Welfare states are dedicated to fighting poverty. This fight indirectly improves public health by reducing material hardship and social exclusion. Health care systems provide access to health care and prevent and cure ill health of the poor by means of timely and affordable health care. In my study, I carry out one case study related to the implementation of the Affordable Care Act in California (ACA in CA) and two comparative analyses of advanced democracies to analyze whether social welfare generosity reduces headcount poverty, and whether health care coverage and health care systems improve the self-rated health status of the poor.
In a first step, cross-national OLS regression analyses created from aggregated national data (source: LIS and OECD) show that social welfare generosity reduces headcount poverty across 21 advanced democracies. However, welfare state effects on poverty reduction decreased between 1990 and 2010. In contrast, the association between health care systems and health inequality is less clear.
In a second step, cross-national multilevel regression analyses display beneficial effects of generous public policy on headcount poverty among 15 European countries in 2010. In contrast, generous health care supply is not the expected moderator of poverty effects on ill health, but only a direct social determinant related to gender-, age-, and economic status- adjusted ill health. I utilize individual data from the European Statistics on Income and Living Conditions (EU-SILC).
In a third step, binary logistic regression analyses of the ACA in CA display that poor adults have less access to health care and were more ill before and after the implementation of the ACA. However, health care coverage moderates the negative poverty effects on health. The main lessons for Europe are that the ACA increases coverage by publicly funded health plans (Medicaid). At the same time, fragmented public and private risk pools undermine the health care system. Individual poverty and health data is based on the cross-sectional Californian Health Interview Survey (CHIS).
My thesis disentangles for the first time the effects of two major social determinants of health, public policy and health care, on the self-rated health status of the poor.
Résumé
Dans les démocraties avancées, la pauvreté est une réalité durable. Les États-providence se consacrent à la lutte contre la pauvreté, qui améliore indirectement la santé publique en réduisant les difficultés matérielles et l'exclusion sociale. Les systèmes de santé donnent accès aux soins de santé et permettent de prévenir et de guérir les maladies des plus démunis, grâce à des soins de santé économiques et délivrés en temps. Dans mon étude, j'effectue une étude de cas relative à la mise en œuvre de l'Affordable Care Act en Californie (ACA in CA) et deux analyses comparatives de démocraties avancées pour analyser si la générosité de l’État-providence réduit la pauvreté. J’examine également si la couverture des soins de santé et les systèmes de santé améliorent l'état de santé autoévalué des pauvres.
Dans une première étape, des analyses de régression (OLS) transnationales, créées à partir de données nationales agrégées (source : LIS et OCDE), montrent que la générosité de la protection sociale réduit la pauvreté dans les 21 pays démocratiques avancés étudiés.
Cependant, les effets de l'État-providence sur la réduction de la pauvreté diminuent entre 1990 et 2010. En revanche, l'association entre les systèmes de santé et les inégalités en matière de santé est moins claire.
Dans une deuxième étape, des analyses de régression transnationales multiniveau montrent des effets bénéfiques d'une politique publique généreuse sur la pauvreté dans 15 pays européens en 2010. En revanche, la générosité de l'offre de soins de santé n'est pas le modérateur attendu des effets négatifs de la pauvreté sur la santé mais seulement un déterminant social direct lié la mauvaise santé, ajusté pour le sexe, l'âge et le statut économique. J'utilise les données individuelles des statistiques de l’UE sur le revenu et les conditions de vie (EU-SILC).
Dans une troisième étape, des analyses de régression logistique binaire de l'ACA in CA montrent que les adultes pauvres ont moins accès aux soins de santé et sont plus malades avant et après la mise en œuvre de l'ACA. Toutefois, la couverture des soins de santé atténue les effets négatifs de la pauvreté sur la santé. Les principales leçons pour l'Europe sont que l'ACA augmente la couverture par un système de soins doté d’un financement public (Medicaid). En même temps, la fragmentation des groupes de risques publics et privés nuit au système de santé. Les données individuelles de la pauvreté et la santé sont basées sur l'Enquête Transversale Californienne sur la Santé (CHIS).
Ma thèse démêle pour la première fois les effets de deux déterminants sociaux majeurs de la santé – les politiques publiques et les soins de santé – sur l'état de santé autoévalué des pauvres.
Acknowledgments
First, I am indebted to my professor Jonas Pontusson. I benefited significantly from our conversations, in which he helped me to focus on my main hypotheses and rethink the concepts of welfare states and health care systems. Second, I wish to acknowledge the input and support of professor Gerald F. Kominski and his colleagues at the UCLA Center for Health Policy Research during my visiting scholars program in 2016. Third, many thanks go to Amber Stiles, who not only proofread the manuscript, but also discussed American society during lively Skype sessions. The same holds for Stephen Keating, who edited the final manuscript.
Finally, I would like to thank the State Secretariat for Economic Affairs (SECO) and especially Pascal Richoz, Maggie Graf and Marc Arial for flexible working hours, which allowed me to work both on SECO projects and on the dissertation.
1. Introduction
Poverty is the dark side of advanced democracies. This structural rupture depends on national welfare state programs, which oscillate between targeting public policy for the deserving needy and universal public policy relative to social citizenship. Against this
background, poverty affects inequality in health across rich nations to different degrees. The lack of economic and societal resources is linked to unhealthy behavior and unfavorable living conditions, including high risk factors and low resources, in the sense of supportive factors, which already in early childhood set an uneven starting point among people. In the context of enduring the shortage of individual opportunities to participate in society, the negative effects on the health status of the poor and on society as a whole are serious. In short, poverty means social exclusion, which is detrimental to health.
Adequate living conditions without poverty, a goal of every welfare state, are a precondition for broad public health. Hence, a lack of substantive liberty leads to the narrow development of individual capabilities, for instance coping capacities to respond to stress, and damages the health status of the deprived population. Certainly, the poor personally bear the brunt of social exclusion and the inability of the welfare state to enact effective poverty policy, but the private market also loses human capital and productivity.
The welfare state and the health care system are two social determinants of health which set the national parameters in order to foster public health and to decrease health
inequality. Social inequalities in health can be defined as systematic and avoidable differences in health outcomes between social groups (Whitehead & Dahlgren, 2006, ), whereby individuals with socioeconomic disadvantages have higher levels of morbidity and consequently shorter lives than those with socioeconomic advantages.
The social determinants of health (Marmot, 2005; Marmot & Wilkinson, 2006; WHO, 2014) are the broader social framework in which people are born, live, work, and finally die. These social factors describe the upstream factors in order to go beyond individual behaviors, which are distributed systematically among socioeconomic groups. The chance to live a healthy life and to enjoy retirement in good shape certainly depends on individual behavior, but foremost on the social position one occupies because the latter influences the former.
Overall, we are vulnerable beings looking for friendly, binding and secure relationships embedded in social structures to satisfy our “ontological security” needs (Turner, 1986, p.
973). Social structures “take the form of a set of interdependent positions that are prior to the interaction between the individuals occupying these positions” (Udehn, 2002, p. 494).
Thus, there is no isolated individual such as Tarzan without a social position in post-industrial society. Human beings can be seen through Friedrich von Hayek’s ontological lenses “as sociocultural beings shaped by social institutions and by the history of society” (Udehn, 2002, p. 482).
The importance of social factors in health inequality, such as well funded public schools, housing quality, air quality, decent working conditions, and access to social security programs and health care, is rooted in the mid-19th century, when scholars from different disciplines documented the devastating effects of miserable living conditions (i.e., poverty)
on health1. For instance, Virchow (1848), a famous social medical scientist in Prussia, urged the government to establish “free and unlimited democracy” against absolutism and nepotism, to counteract the hunger-typhus outbreak in Upper Silesia, a poor rural area, in 1848. He identified social causation as the main driver of the infectious disease when he claimed that a “disease is not something personal and special, but only a manifestation of life under (pathological) conditions…Medicine is a social science and politics is nothing else but medicine on a large scale (Virchow 1985(1848):33). This striking statement highlights the link between the upstream factors of public policy and health care and the downstream factor of poverty on health outcomes.
In modern society life expectancy rose continuously from 70 years in 1960 to 81 years in 2010. While infant mortality declined, infectious diseases were mainly replaced by chronic diseases (i.e., cardiovascular disease, respiratory disease, cancer, and dementia). Following J.
P. Mackenbach, Karanikolos, and McKee (2013) the main reason for the western success story is based on the combined effects of economic growth, improved health care, and successful health policies (e.g., tobacco control, road safety).
Despite the epidemiological transition and higher life expectancy, social inequality in health across social positions remains important in advanced democracies. Mackenbach et al.
(1997) show that 11 European countries face inequalities in health, both related to self- reported health status and mortality, though the magnitude varies. The pronounced health inequality in Norway and Sweden, two countries with universal and egalitarian public policy, is at odds with supposed equal health outcomes in social democratic welfare states. Ten years after the first cross-national mortality study, Johan P. Mackenbach et al. (2008) conducted another remarkable study, which included 22 European countries in the decade of the 1990s. Again, the degree of inequality in morbidity and mortality varies between countries. While southern European countries exhibit small education-related inequalities in mortality, most countries in the eastern and Baltic regions have high inequalities. The
analysis of the occupational class inequality in male mortality confirms the favorable
standing of the southern European countries. The Nordic countries occupy a middle position.
The health gradient, which shows that health follows social hierarchy with successively better health for every step up the ranking, became a center concept in social epidemiology after the Black Report (Black, Morris, Smith, & Peter, 1992) and the Whitehall II study (Marmot et al., 1991). The famous Whitehall II cohort study demonstrates that British civil servants at higher occupational hierarchies have better health outcomes than their
colleagues at the lower end of social ladder. The age-standardized mortality rate of male adults 40 to 64 years of age, over a ten-year period, was about 3.5 times higher for clerical assistants and manual workers than for senior officers.
The social gradient in health outcomes, either measured by mortality, morbidity, or self- reported health status, is present all along the social ladder for both genders (M. Shaw, Dorling, & Smith, 2006, pp. 196-200). In other words, people in lower socioeconomic positions have poorer health than those in higher positions. My thesis shows that the poor
1 Engel (1844) described the effects of the miserable working conditions of the Industrial Revolution on workers in England.
Villermé (1826) analyzed the relationship between poor housing conditions and increased mortality in Paris. Durkheim (1897) compared the anomie of societies by investigating the suicide rates in various religions, and Chadwick (1842) linked the Poor Laws with sanitation and public health outcomes.
are less likely to say that their health is good or very good than the well-off are. Roughly 60 to 70 percent of the poor perceived their health as good or very good in the advanced democracies in 2010. Conversely, this number rises to around 80 or 90 percent for the well- off.
In my eyes, the welfare state, together with the health care system, builds two major upstream factors important for the health status of the poor. To put it simply, the welfare state represents the public policy which provides security and stability against market vagaries and reduces poverty. These social security policies represent the primary
prevention approach to prevent poverty-related diseases before they occur. In contrast, the health care system is mainly a curative institution with a secondary prevention orientation. It aims to soften the effects of disease or injury when they have already occurred.
While scholars stress that adequate living conditions are important for better health outcomes of the poor (Black et al., 1992, p. 165), my analysis shows the welfare state is an indirect health factor, which improves living conditions by reducing headcount poverty due to income replacement. However, when poverty effects are controlled, the welfare state has no effect on the health status of the poor. In respect to health care, health care systems turn out to be a direct health factor independent of poverty effects, and health care coverage moderates the damaging poverty effects.
To study these associations my cross-national approach is supplemented with a case study of the recent American health care reform, namely the Affordable Care in California (ACA in CA). Despite a large decrease in uninsured rates and an increase in public health care
coverage, the United States is the only country in the rich world where health care coverage is not universal. In this sense, the fragmented American social health insurance system provides an interesting benchmark for European countries with universal health care coverage and shows that health care coverage moderates the poverty effects on ill health.
Health care coverage is one of the principal resources when a person falls ill or has an accident, but also for timely preventive advice and measures (e.g., in relation to pregnancy, maternity, and newborn care). Health insurance integrates a person into society by providing medical treatment at a reasonable price and wage continuation. A lack of health care
coverage causes health problems and material hardship, which counteract adequate living conditions. The potential financial shortcomings and fear of bankruptcy weigh heavily on an individual’s psychological stress level, especially in a society where poverty is linked to individual failure. In addition to curative health care, preventive health care, such as
prevention of addiction, can be financed and coordinated by public health care coverage. In this respect, social inclusion and capability enhancement by not becoming sick enable
participation in daily life with less fear and stress. The poor become, to a greater extent, able to participate in society and are therefore less ill.
All advanced democracies experience inequality across socioeconomic positions, albeit that the magnitude of inequality varies among nations. Against this background, I ask how effective are national public policies to prevent and eradicate poverty and how successful is the health care system in fostering good health for the most vulnerable people in 21
advanced democracies?
In general, poverty negatively affects health status through two principal pathways (e.g., Bambra, 2012; Hertzman & Siddiqi, 2009, pp. 43-44; M. Shaw et al., 2006, pp. 200-201). First, the principal link of ‘material hardship’ describes the lack of income to buy goods and
services on the private market. This concerns, for instance, healthy food, appropriate accommodation, sporting facilities, holidays, transportation, education, and private health treatment (e.g., dental treatment). Poor people suffer frequent social health risks such as a low level of control in the workplace, physically demanding working conditions, unstable employment and (long-term) unemployment, and weak neighborhood support. Under these conditions, people show adverse health behaviors, low resilience, little knowledge about nutrition, and poor cognitive skills to get access to timely health care. I claim that these risk factors are caused less by individual failures or bad choices, but more by society. However, from a societal view, more important than the moral discussion about the responsibility of the poor and society, is the fact that under material hardship people are not able to develop and take advantage of their skills and knowledge. This waste of talent undermines human capital.
Second, the psychosocial literature underlines the fact that national culture and dominant ideology are important social determinants of health. In societies in which the welfare state fosters universal solidarity through comprehensive social security policy, poverty is
ideologically less linked to individual failure, slovenly character, or personal immorality than in a libertarian society, in which the welfare state is perceived as a hammock and the poor as suspect and indolent2.
The ‘material hardship’ pathway and psychosocial pathways are interdependent and shaped by different welfare states and health care systems. These social determinants of health can enhance social inclusion and mitigate personal stress by tackling poverty as a societal topic.
Hence, the psychosocial environment of the poor is probably more favorable in a society based on equality than on hierarchy or meritocracy.
In sum, under the condition of material hardship, the social determinants of health tend to be more on the exposure side than on the relief side, but welfare states and health care systems mediate the impact. Various national and cross-national studies show that
disadvantaged people feel less healthy during their lives and they die earlier than the well- off in the rich world. While inequalities in health are a systematic reality in every rich nation, the magnitude of this political failure differs depending on the welfare state and the health care system (Bergqvist, Yngwe, & Lundberg, 2013). In my opinion, these two social
determinants of health are fundamental political institutions to explain first, cross-national differences in poverty outcomes and second, inequalities in health between the poor and the non-poor population in the 21 advanced democracies.
2 Additional theories in relation to the materialist and psychosocial explanation of socioeconomic inequalities in health are:
1) the artefact approach, which claims that health inequalities are merely caused by flawed data and measurements. Thus, there are no real health inequalities. 2) the health selection approach, which suggests that health status affects
socioeconomic position and not that socioeconomic position affects health outcomes. For example, ill health causes unemployment or precarious work, rather than that unemployment is the reason for ill health. 3) the cultural-behavioral approach, which asserts that unhealthy behavior (e.g., smoking, drinking, eating a high-fat diet, not doing exercise, etc.) is culturally more accepted, and thus more common, at lower levels of the social hierarchy than at higher levels. 4) the life course approach, which is built on various elements of the other approaches related to different diseases. Inequalities in health result from a combination of material, psychosocial, and behavioral factors to different degrees throughout a person’s lifetime (Bambra, 2012, pp. 146-147).
My thesis elaborates on the effects of both public policy and health care on the health outcomes of the poor. What is at stake is the cross-national effectiveness of public policy and health care in providing healthy living conditions and access to health care for all citizens irrespective of income. In this sense, the intersection of these two independent social
determinants of health influence headcount poverty, which is a serious downstream factor in ill health.
My thesis adds cross-national evidence to the literature on the social determinants of health, in which the health care system is a main theoretical factor (WHO, 2014, p. 5) but less an independent variable to explain empirically cross-national health outcomes (e.g., Beckfield, Olafsdottir, & Sosnaud, 2013).
Cross-national evidence is inconsistent regarding the effects of the welfare state and nonexistent when considering the health care system in relation to health inequality. By bringing together the welfare state literature and the health care literature I fill two research gaps (Brady, Marquardt, Gauchat, & Reynolds, 2016, pp. 358-360). First, the rich quantitative cross-national welfare state literature informs the more case study orientated health care literature. In this respect, my thesis presents social welfare generosity (Scruggs, 2014; Lyle Scruggs, Detlef Jahn, & Kati Kuitto, 2013a). Second, the health care system is introduced into welfare state literature, which mainly focuses on sickness, unemployment, and pension insurance schemes.
The main goal of my thesis is to disentangle the effects of welfare states and health care systems on the health status of the poor. To my knowledge, this is the first time that these two independent social determinants of health have been scrutinized together. I expect that the welfare state is an indirect social determinant of health by reducing headcount poverty.
In contrast, the health care systems in 21 advanced democracies and health care coverage in California are assumed to be moderators of poverty effects. To test these upstream factors I perform a case study and two cross-national analyses. In the end, we have to look to
California to detect moderating effects of health plans, because health care supply in Europe is not a moderator but only a direct social determinant of health.
In a first step, I discuss my social policy approach and present social welfare generosity and a new health care system measurement by means of a principal component analysis. In a second step, I use these two social determinants of health to scrutinize cross-national health inequality based on macro data from 21 advanced democracies. In a third step, the welfare state and health care system effects on individual poverty and health data across 15
European countries are analyzed by means of multilevel analysis. In a fourth step, I use logistic regression analysis to examine the enactment of the Affordable Care Act in California in 2013-14. The following paragraphs briefly outline the objectives, the core arguments, and the major findings of each analysis chapter.
The first analysis chapter investigates first, the concepts of public policy, and second, health care systems. The comparative welfare state literature offers a rich debate on the
appropriate way to capture the complex design of national public policy (Abrahamson, 1999;
Arts & Geliessen, 2002; Pierson, 2000). In my eyes, the welfare state regime approach and the public policy approach are the two main approaches. In a first step, public policy is analyzed by social welfare generosity (Scruggs, 2006, 2007, 2014; Scruggs et al., 2013a) in
order to go beyond the welfare state regime approach based on decommodification (Esping- Andersen, 1990, 1999). In this sense, my thesis illustrates the public policy approach, which uses more sophisticated continuous measurements, instead of welfare state regimes as categorical intervening contexts. The social welfare generosity score is the extension of decommodification (Esping-Andersen, 1990) and clarifies more accurately the welfare state design. The characteristics of welfare states, including misfits and changes, are identified without forcing classification into an ideal type.
In a second step, concepts of health care systems are presented. The comparative literature on health care provides ideal types such as the ones found in studies by Esping-Andersen (e.g., Immergut, 1992). My starting points are four health care systems based on the public- private mix in regulation, financing, and provision (Böhm, Schmid, Götze, Landwehr, &
Rothgang, 2013). First, the Nordic countries, the southern countries, and the United Kingdom are characterized by a national health service system. Second, national health insurance systems are found in Australia, Canada, Ireland, and New Zealand. Third, Belgium, France, and the Netherlands are etatist social health insurance systems. Finally, the social health insurance system is exemplified by Austria, Germany, Japan, Switzerland, and the United States. On the continuum from the first to the fourth health care system, government control decreases and private market control increases.
To overcome the simple ideal typical approach, I develop a new health care measure, which fuses the qualitative classification with data on health expenditure, health care financing, and health care employment by means of a principal component analysis. My thesis reduces extensive data material to two linear components, a health care supply dimension and a health care institution dimension.
The aim of this descriptive and explorative chapter is to present updated measurements of public policy and health care systems, which have rarely been used in comparative public health science, which is linked to the outdated welfare state regimes, namely liberal, conservative, southern, and social-democratic types. The widely applied welfare state
regime approach is linked to the public health puzzle of unequal Nordic countries in terms of health outcomes because the country classification into regimes masks the differences among the Nordic countries (Bambra, 2007, 2011). My public policy approach shows that there is no such issue as the ‘public health puzzle’ because the Nordic welfare states have not been unified into a social democratic welfare state regime or Nordic national health service since 1990. I would like to break with the imprecise typological thinking of the regime approach (Esping-Andersen, 1990), which is still deeply anchored in social epidemiology, where the new insights of comparative political science about the hybrid characteristics of welfare states have not really arrived yet.
The second analysis chapter examines the effects of social welfare generosity and health care systems on health inequality across 21 advanced democracies by means of ordinary least square regressions. The goal of the cross-national analysis based on macro data is first to analyze the effects of welfare states on headcount poverty reduction. Second, poverty effects on the health outcomes of the poor are assessed. Finally, the chapter sheds light on the effects of welfare states and health care systems on health inequality.
On one hand, the effects of public policy on poverty outcomes are clear. Generous welfare states reduced headcount poverty in 1990, 2000, and 2010. Furthermore, rising headcount poverty increased health inequality. The welfare state emerges as an indirect social health determinant. On the other hand, health care system effects on health outcomes are more confusing because I detect no association between the changes in health care systems and changes in health inequality, when changes in headcount poverty are controlled. A major reason is to be found in the macro level data, which does not capture individual-level determinants of health.
The third analysis chapter sheds light on the individual health status of the poor across 15 European countries in 2010. The analysis is divided into first a descriptive analysis and second a multilevel regression analysis based on individual income and health data (EU- SILC). The goal of this cross-national analysis is to investigate to what extent welfare states and health care systems at the macro level affect individual poverty and health.
The descriptive section shows that despite universal coverage in Europe, the poor have unequal access to health care, though not to the same extent as poor Californian adults with health care coverage. Moreover, the poor with timely access to necessary medical
examinations report less ill health than the poor without access to health care.
As had been assumed, there is no direct link between social welfare generosity and subjective ill health, when harmful poverty associations are controlled. In contrast, health care supply (principal component score of health care employment, public health care expenditure, and total health care expenditure) does not moderate the negative poverty effects on health, but is negatively associated with poverty adjusted ill health. In contrast to social welfare generosity, generous health care supply is associated with less ill health, independent of headcount poverty. Overall, the cross-national multilevel analyses only confirm my hypotheses related to welfare state effects and poverty effects. They show that income replacement is an effective indirect public health policy in the EU-15. It prevents poverty related illness.
The fourth analysis chapter describes in the first section the American social health
insurance system and the changes due to the enactment of the Affordable Care Act in 2014.
Then the results of the descriptive analysis and the logistic regression analyses related to the Affordable Care Act in California are presented.
My thesis shows that health care coverage improves access to health care and moderates the poverty effects on ill health. However, because the ACA was enacted within the existing social health insurance system, the fragmented health care system remains. This is an important lesson for the European social health insurance systems, namely those of Switzerland, Germany, and Austria, because stratified public and private health plans
provide unequal access to health care and divide society into good and bad risk pools. I claim that sketchy risk pooling of ‘work-conditioned’ health care without mandatory basic health insurance is not an effective public policy.
1.1 Literature review: welfare state effects on health inequality
The effects of the welfare state on the health status of the poor are presented by the research strand of the social determinants on health inequalities (Dahlgren & Whitehead, 1991). Against the background of the social determinants of health, which underline the manifold psycho-biological and social influences on health status, I focus on the comparative welfare state literature relative to health inequalities (Beckfiel & Krieger, 2009; Bergqvist et al., 2013; Brennenstuhl, Quesnel-Vallée, & McDonough, 2012; Muntaner et al., 2011).
Following Bergqvist et al. (2013), research on welfare state effects on health inequalities has gathered a growing body of evidence over the last decade. However, the cross-national studies are rather inconsistent and do not show a clear picture of the beneficial effects of generous welfare states on the health status of vulnerable populations. The ‘public health puzzle’ appears, as the Nordic welfare states are not characterized by the smallest health inequalities (Bambra, 2011).
The literature review underlines the need to overcome the simple welfare state regime approach to resolve the public health puzzle. More precisely, the welfare state regime approach in public health science mainly refers to decommodification (Esping-Andersen, 1990), which is built on outdated data and imprecise scoring techniques (Scruggs & Allan, 2006b). Moreover, it shows that elements of health care systems are missing in comparative welfare state research. After the literature review, my conceptual framework (cf. section 1.2) and the macro data analysis of the welfare state and the health care system (cf. Chapter 2) will present a novel approach to fill these research gaps. The causal pathways are
characterized by an indirect link between welfare states (i.e., social welfare generosity) and health outcomes via poverty and the moderating role of health care systems and health plans.
This section presents first a summary of the cross-national studies of health inequalities referring to the latest literature review (Bergqvist et al., 2013). This literature review is particularly interesting for my purposes, since it refers to four previous literature reviews (Beckfiel & Krieger, 2009; Brennenstuhl et al., 2012; Lundberg, Aberg Yngwe, Kölegard Stjärne, Björk, & Fritzell, 2008; Muntaner et al., 2011) and summarizes compelling evidence related to public policy and health inequality.
To gather the latest studies, I ran a literature review for the current period (2013-02-28 to 2018-01-01), which was not covered by previous reviews. Consistent with Bergqvist et al.
(2013), I use the database (PubMed and Google Scholar) and the following key words related to public policy and health inequality: ((social polic* or health polic* or pension polic* or unemployment polic* or family polic*) AND (health inequalit* or health inequit* or health disparit*) AND (Humans[Mesh])3) (Bergqvist et al., 2013, p. 3).
My search produced 720 citations in PubMed and 391 citations in Google Scholar. From these, I add 4 relevant studies to the 20 studies of Bergqvist et al. (2013). My inclusion criteria are: 1) a peer reviewed study, which is published in an international journal, 2) cross- national study, 3) uses multilevel regression or pooled cross-sectional time series analysis, 4)
3 Medical Subject Headings
addresses inequality in mortality or morbidity (by education, income, or occupational class), and 5) refers to advanced democracies.
Bergqvist et al. (2013) distinguish between three main approaches in comparative welfare state research, namely, the regime approach, the institutional approach (i.e., specific public policy), and the expenditure approach. In sum, 24 studies were selected between 2005 and 2013 from which 18 studies follow the regime approach and 6 studies use the institutional approach.
The welfare regime approach is the most popular approach in the field of social
determinants of health (Esping-Andersen, 1990; Ferrera, 1996; Huber & Stephens, 2001). I claim that this approach offers only imprecise ideal typical concepts to measure population health (levels of mortality and morbidity) or socioeconomic inequalities in health.
Interestingly, this approach is linked to the ‘public health puzzle’ of unequal health status in Nordic countries despite the assumed coherent social democratic decommodification pattern. The second approach, the public policy approach, illustrates my approach (i.e., social welfare generosity). This approach is less popular but seems to provide more consistent results because of a more sophisticated operationalization of singular public policy. The third approach of expenditure is rarely used to explain health inequality. In my eyes, this approach is too simplistic because it does not take into account the design of the welfare state. In short, the expenditure measure is sensitive to economic cycles and only informs us about how much is spent but not how the social security benefits are provided.
For instance, recessions/booms increase/decrease the numerator in terms of vulnerable people and even more importantly change the denominator in respect to falling/rising GDP.
The following paragraphs summarize first the literature based on the welfare state regime approach and second on the public policy approach.
Welfare state regime approach
Related to the regime approach, Bergqvist et al. (2013) assert important differences in the results. In the following paragraphs, I present the results of 18 studies based on welfare state regimes, which scrutinize health inequality. The aim of this exercise is to show, first, the diversity of the research design related to the country sample and measures of health inequality, and second, how sparse the evidence is in reference to lower health inequality in the social democratic welfare regime.
In reference to the typology of Esping-Andersen (1990), which divides the advanced democracies into liberal,4 conservative,5 and social democratic6 welfare state regimes, Sekine, Chandola, Martikainen, Marmot, and Kagamimori (2009) provide cross-sectional evidence that health inequality in terms of the physical functioning of civil servants is lower in Finland than in the UK and Japan. In contrast, two longitudinal studies show that the conservative welfare state regime is characterized by low health inequality in terms of the mortality of adults (Harding et al., 2013) and in the self-rated health of adults (Sacker, Worts,
& McDonough, 2011). Using cross-sectional data of 31 countries, Zambon et al. (2006) assert, on one hand, lower inequalities in self-rated health in liberal and eastern regimes,
4 Australia, Canada, Ireland, New Zealand, the UK, USA
5 Finland, France, Germany, Italy, Japan, Switzerland
6 Austria, Belgium, Denmark, the Netherlands, Norway, Sweden
and, on the other hand, lower inequalities in general well-being and in the number of symptoms in liberal and southern regimes than in social democratic regimes.
Referring to the typology of Ferrera (1996),7 which adds basically a southern regime to the threefold typology of Esping-Andersen, a large majority of the studies contradict the expected finding of more equal health outcomes in the Nordic countries, despite their redistributive and comprehensive public policy.
Bambra and Eikemo (2009) find that self-reported health inequality between the employed and unemployed population among 23 European countries is higher in the Anglo-Saxon, Bismarckian, and Scandinavian regimes than in the Southern or Eastern regimes. Moreover, women in Scandinavian regimes exhibit higher health inequality compared to those in Bismarckian, Southern, and Eastern regimes. In the same vein, income-related health inequality (Terje. A. Eikemo, Bambra, Joyce, & Dahl, 2008) and education-related health inequality (Terje A. Eikemo et al., 2008) are not the lowest in the Nordic regime, since the Bismarckian regime experiences lower inequalities. Furthermore, gender inequality in the social democratic regime and the Southern regime is higher than in the Bismarckian regime where gender inequality tends to be lower. This is at odds with the expected lower
inequality in the social democratic regime, which is founded on gender neutral social citizenship (Bambra et al., 2009).
The next study on overall inequality in mortality shows that the Nordic countries have the lowest inequality for men and younger age groups, but not for women, among 37 countries (Popham, Dibben, & Bambra, 2013). Female inequality in mortality is the lowest in the Southern regime followed by those of the Bismarckian, Nordic, and finally the Anglo-Saxon regimes. In contrast, Van der Wel, Dahl, and Thielen (2011) compare 26 countries and find some evidence for better health outcomes in the Nordic countries. On one hand, the prevalence of longstanding limiting illness is lower in the Scandinavian regimes than in the Southern and Bismarckian regimes and especially than in the Anglo-Saxon regime. On the other hand, the Southern regime is characterized by the lowest educational inequalities in subjective ill health for men. In contrast, women in the Scandinavian regime have the lowest inequalities in sickness.
Another cross-national study of 17 European countries shows that educational inequalities in self-reported health in Europe tend to be lower in the Bismarckian and Southern regimes than in the Scandinavian regime (Bambra, Netuveli, & Eikemo, 2010). This is confirmed by Richter et al. (2012) related to low inequality in self-rated health among adolescents in the Southern regime.
Let us move on to the two cross-national studies based on the typology of Huber and Stephens (2001). This typology, which is based on prevailing political tradition, treats Australia and New Zealand not as a liberal but as a wage-earner regime. The other three regimes -- liberal, Christian democratic, and social democratic -- are similar to Esping- Andersen’s typology.
7 The typology is built on coverage, replacement rates, and poverty rates and refers to European countries: 1) Anglo-Saxon regime: Ireland, and the United Kingdom, 2) Bismarckian regime: Austria, Belgium, France, Germany, Luxembourg, the Netherlands, and Switzerland, 3) Scandinavian regime: Denmark, Finland, Norway, and Sweden, 4) Southern regime: Italy, Greece, Portugal, and Spain. Two studies add an Eastern regime to the original typology (Bambra & Eikemo, 2009; Terje A.
Eikemo, Huisman, Bambra, & Kunst, 2008).
In reference to the elderly population (50 to 74 years), among 9 European countries Espelt et al. (2008) show that social class inequality in self-perceived health is higher in late
democracies (Portugal and Spain) than in social democratic democracies (Sweden, Denmark, and Austria). Borrell et al. (2009) present a similar result related to educational-level
inequalities in self-perceived health. Based on a sample of 13 European countries, social democratic regimes are found to have the lowest inequalities for both men and women.
The next three studies are based on pooled cross-sectional time series analysis or multilevel regression analysis (individuals at level 1-units and country at level 2-units) and use Ferrera’s (1996) typology (Anglo-Saxon, Bismarckian, Scandinavian, Southern regimes) plus the
Eastern regime.
J. Fritzell, Kangas, Bacchus Hertzman, Blomgren, and Hiilamo (2013) analyze the macro data from 26 countries from 1980 to 2005 by means of pooled cross-sectional time series
analysis. The welfare state impacts strongly on relative poverty, and relative poverty matters for infant mortality (aged <1 year). Infant mortality rates are higher in the Central Europe, liberal, and especially post-socialist regimes compared to that of the Nordic regime.
Remarkably, the Southern regime does not differ from the Nordic regime. These regime effects are independent of differences in relative poverty, economic prosperity, and social spending. In respect to child mortality (1 to 17 years of age), the liberal and the Southern regimes perform better than the Nordic regime, when confounders are controlled. The other welfare state regimes do not contrast with the Nordic regime.
In respect to female mortality rates, J. Fritzell et al. (2013) observe that the Central regime and especially the Southern regime fare better that the Nordic regime. This holds when the positive effect of poverty and the negative effect of GDP and social spending are considered.
The post-socialist regime has the highest female mortality rates, independent of relative poverty, GDP, and social spending. In reference to male mortality, the authors detect higher adjusted male mortality in the Nordic regime than in the Southern and the liberal regimes.
The findings relative to adult mortality are related to a counterintuitive combination of high poverty rates and high life expectancy in the Southern regime. In the end, the Nordic regime loses its favorable ranking related to infant mortality when the focus turns to adult health status, despite generous and universal social policy.
Rathmann et al. (2015) scrutinize to what extent macro level determinants (national income, health expenditures, income inequality, and welfare regimes) are associated with inequality in the subjective psychosomatic health of young people. Using cross-national data from 27 European and North American countries, the authors show, by means of multilevel
regressions, that socioeconomic health inequality is higher in the liberal welfare regime (Canada, the UK, the USA) than in the social democratic welfare regime (Finland, Norway, Sweden). Youth health in conservative, Southern and Eastern regimes is similar to that of the social democratic welfare regime.
Related to the workforce (25-59 years) in 20 European countries, R. J. Shaw, Benzeval, and Popham (2014) find that the highest rates of subjective good health are to be found in the Anglo-Saxon and the Nordic welfare state regimes. Bismarckian and Southern countries occupy a middle position and the Eastern Europe and former Soviet countries display the
lowest levels of good health. However, the Nordic welfare regime, in which egalitarian public policy is supposed to flatten the health gradient, is characterized by large health inequalities between the salariat and the working class. Conversely, health inequality in the Southern regime is below the European average.
The last study of the literature review, which scrutinizes health inequality by regime types, uses the typology of Korpi and Palme (1998).8 Sanders et al. (2009) analyze to what extent welfare states influence the income gradients in oral health in 1998-2002. The sample contains Germany, Finland, the UK, and Australia, which represent the Corporatist, Encompassing, Basic Security, and Targeted welfare states, respectively. The findings are partly in the expected direction since the Finnish poor, who have encompassing social insurance, exhibit the best average dental health, followed by Germany (corporatist
scheme), the UK (basic security), and finally Australia (modest targeted programs). However, in terms of income inequality in oral health, Germany, with its universal and earnings-related social security scheme, is the model example, since it is the only country where no inequality was found. Finland, in contrast, where the encompassing welfare state ensures universal access to public health insurance, has a pronounced income inequality in dental health.
A brief summary of the 18 studies on inequality in health presented shows first the variation in study design related to country selection, health measures, and statistical methods.
Second, the public health puzzle - the social democratic welfare state regime, which is supposed to perform better than other welfare states in terms of health inequality because of the encompassing welfare state – appears in different subpopulations, such as the elderly, adolescents, and the workforce.
In sum, only 3 out of 18 studies display the expected equal Nordic pattern in terms of health outcomes (Borrell et al., 2009; Espelt et al., 2008; Popham et al., 2013). Thus, cross-national evidence stresses that the social democratic welfare state regime, which is based on high levels of decommodification and low levels of stratification (i.e., universal public policy programs and equal social security benefits), is characterized by surprisingly large health inequality.
Public policy approach
Related to the public policy approach,9 Bergqvist et al. (2013) detected 5 studies which shed light on health inequality. While there are no health inequality studies related to pension benefits, I extract one study related to social assistance (cash assistance), one study related to family benefits and three studies related to access to health care. Two out of the five studies found decreasing inequalities due to public policies. I add one recent study referring to unemployment replacement rates, which shows negative effects on health inequality.
8 In their influential article Paradox of Redistribution, Korpi and Palme (1998) distance themselves from the idea of a powerful ideology of incumbent political elites shaping distinct welfare state clusters around distinct regime types. The complexity of national social policy legacies prevents Korpi and Palme from using the concepts of decommodification and stratification as analytical tools to distinguish discrete welfare state regimes. Instead, they argue that the welfare state should be considered to be social transfer arrangements, which redistribute social security benefits. On the basis of sickness insurance and the old age pension, they draw a distinction between targeted (Australia), voluntary state-subsidised (no country fits), corporatist (Germany, Austria, Belgium, France, Italy, and Japan), basic security (the UK, Canada, Denmark, the Netherlands, Ireland, New Zealand, Switzerland, and the United States) and encompassing social insurance schemes (Finland, Norway, and Sweden).
9 Note: Bergqvist et al. (2013) called it the institutional approach.
S. Fritzell, Ringbäck Weitoft, Fritzell, and Burström (2007) scrutinize the health of Swedish single mothers before and after the economic downturn in the early 1990s. Overall, the declining employment rate of single mothers was accompanied by a policy change of
decreasing social security benefits. Against this background, single mothers expressed worse self-rated health than mothers with a partner during the whole period between 1983 and 2001. Furthermore, they had higher risks of hospitalization and mortality before and after the crisis. Interestingly, the expected increasing inequality in health due to deteriorating living conditions did not take place. The authors assume that the shrinking welfare state still cushioned negative health effects for single mothers.
The next paper assesses inequality in health between single mothers and mothers with a partner in Sweden, Italy, and Britain (Burstrom et al., 2010). The focus is on different family policy models and their effects on self-assessed health and limiting longstanding illness.
While single mothers suffer from poverty, unemployment, and ill health in all three
countries, the Swedish dual-earner family policy and generous family benefits offer effective protection against poverty and ill health compared to the British market-orientated family policy model and the Italian general family policy model. Moreover, Sweden provides more jobs, which promote private welfare, to single mothers than Britain and especially Italy.
Strikingly, absolute and relative inequality in self-rated general health between single mothers and mothers with a partner were lower in Italy than in Sweden and Britain. I
conclude that the Swedish family model performs better in terms of the level of ill health but not in terms of inequality in health.
Let us now turn the spotlight to the three mortality studies related to access to health care in Barcelona, Canada, and Australia. First, Borrell et al. (2006) show that AIDS mortality declined because of the introduction of highly active antiretroviral therapy (HAART) in Barcelona in 1996. However, inequality in AIDS mortality remained rather stable after the implementation of HAART because the gap between lower socioeconomic groups (deprived neighborhood and low education) and the better-off population did not decrease. The authors assume that a certain lack of access for vulnerable populations persisted despite the universal program.
In reference to the introduction of the Canadian universal health insurance, James, Wilkins, Detsky, Tugwell, and Manuel (2007) show that avoidable mortality10 in low income
neighborhoods declined substantially. The establishment of universal insurance for visits to practitioners (1968) and use of hospital service (1957) noticeably decreased income-based absolute inequality in mortality amenable to medical care between 1971 and 1996.
In Australia, Korda, Butler, Clements, and Kunitz (2007) observe a twofold trend related to mortality amenable to health care between 1986 and 2002. Health care has contributed to declining avoidable and non-avoidable mortality at both the low and high ends of the socioeconomic spectrum. However, the decrease in avoidable mortality (compared with non-avoidable) was more pronounced among the better-off. This uneven trend results in widening relative health inequality. The authors conclude that a universal national health
10 Avoidable mortality refers to amenable and preventable deaths. “A death can be considered as amenable if it could have been avoided through optimal quality health care. The concept of preventable deaths is broader and includes deaths which could have been avoided by public health interventions focusing on wider determinants of public health, such as behavior and lifestyle factors, socioeconomic status, and environmental factors” (Eurostat (2016), Statistics Explained).
insurance system does not necessarily lead to equality in health-care-related outcomes because various barriers to timely care could persist (i.e., behavior related to ill health, less preventive orientation, inequality in quality of care).
The last paper related to the public policy approach analyzes health inequality between the unemployed and employed populations and the moderating effect of the welfare state in 23 European countries (Vahid Shahidi, Siddiqi, & Muntaner, 2016). In all countries, the
unemployed population is less healthy than workers, though the magnitude of this
inequality varies considerably. By means of multi-level logistic regression, the authors show that the level of social protection, measured by the national unemployment insurance replacement rates (CWED data), affects self-rated health inequality. Overall, generous unemployment policies reduce health inequality in Europe.
The literature review above shows that there is little evidence of a flat health gradient in the social democratic welfare states. The confusing findings with even contradictory results are partly due to different and modified typologies, country sample, country classification, periods, and measures of health inequality. These variations in study design inhibit any concise conclusion related to the expected lower health inequality in generous and comprehensive Nordic welfare states (Brennenstuhl et al., 2012, p. 399). However, I claim that the main problem arises from the welfare state regime approach, which falsely clusters the Nordic countries into one family. My public policy approach highlights pronounced variations among the Nordic countries in regards to social welfare generosity and health care.
In reference to my study design, I underline that cross-national health inequalities are usually measured by education or work status but rarely by poverty levels. I count only one study (J. Fritzell et al., 2013) which uses poverty as the main independent variable to explain health outcomes. Moreover, no study measures public policy by social welfare generosity and uses the EU-SILC data to measure the effects of public policy on the self-rated health status of the poor.
1.2 The conceptual framework
The conceptual framework of my thesis is based on the social determinants of health (Dahlgren & Whitehead, 1991; WHO, 2014), which are “the circumstance in which people are born, grow up, live, work, and age, and the systems put in place to deal with illness.”
Living conditions vary across advanced democracies, where unequal opportunities and social exclusion shape the health outcomes of the poor. To sort the manifold socioeconomic, political, and cultural influences on health my thesis concentrates on two pivotal health determinants: the welfare state and the health care system. The interplay of these two upstream factors is particularly interesting since they appear at different stages in the causal pathway.
First, the welfare state as a preventive health institution affects the social position of
individuals by providing social security benefits and social services when private workfare or family provision is insufficient to live a decent life.
Second, the health care system, as mainly a curative social determinant of health, provides access to timely, high-quality and affordable health care services, ideally irrespective of one’s income. In this respect I analyze the effects of health care systems in advanced
democracies and the effects of various health plans in California. The American social health insurance system is the most market maximizing health care system in advanced
democracies and provides a fertile ground to compare access to health care between public health plans, private health plans and the uninsured population. To put it simply, the
positive effect of health insurance on health status is mediated through better access to needed health care. The uninsured have poor access to health care.
Furthermore, the Affordable Care Act (ACA) increased health care coverage considerably for the poor between 2013 and 2014. However, there is still a substantial uninsured population since the health care reform took place within the stratified health care system. This natural experiment is a unique research opportunity to assess pre- and post- reform health care outcomes in terms of access and the health status of the poor because all other advanced democracies provide universal and mandatory basic health care coverage.
In respect to downstream factors, my thesis uses poverty to assess health status. My model refers to the popular theoretical link between public policy and health status via an
intervening social position variable. Social position is the proximal outcome, and health status the distal outcome, of public policy (Borell, Espelt, Rodriguez-Sanz, & Navarro, 2007;
Coburn, 2004).
I assume that welfare states have an indirect effect via poverty on public health. Health care systems and Californian health plans are expected to have a direct effect on public health by moderating the harmful effects of poverty. The next figure shows the causal pathways.
Figure 1-1: Conceptual framework
The causal pathways shown in Figure 1-1 start with the welfare state, which is part of a wider socioeconomic, political, cultural, and environmental framework. Within a specific national context, public policy exhibits different levels of social welfare generosity. The different designs of national public policies are caused by unevenly dispersed political power among various parties, unions, and interested groups, as well as by mature political
institutions with different veto points (i.e., executive power fragmentation, decentralized
