HEALTHY MINDS IN HEALTHY BODIES: AN INTERNATIONAL COMPARISON OF EDUCATION‐RELATED INEQUALITY IN PHYSICAL HEALTH AMONG OLDER ADULTS
| Published date | 01 July 2009 |
| Date | 01 July 2009 |
| DOI | http://doi.org/10.1111/j.1467-9485.2009.00485.x |
| Author | Hendrik Jürges |
HEALTHY MINDS IN HEALTHY BODIES:
AN INTERNATIONAL COMPARISON OF
EDUCATION-RELATED INEQUALITY IN
PHYSICAL HEALTH AMONG OLDER
ADULTS
Hendrik Ju
¨rges
n
Abstract
We study education-related inequality in the physical health of older adults across
11 European countries and the United States. Combining the data from Health and
Retirement Study 2002, the English Longitudinal Study of Ageing 2002 and the
Survey of Health, Ageing and Retirement in Europe 2004, our results suggest that
education is strongly correlated with health both across and within countries.
Education-related inequality in health is larger in Mediterranean and Anglo-Saxon
countries than in western European countries. We find no evidence of a trade-off
between health levels and equity in health. Education-related inequality in health is
hardly driven by income or wealth effects (except in the United States), and
differences in health behaviours (smoking) by education level contribute little to
health differences across education groups.
I Intro ductio n
A strong relationship between socio-economic status and health has been
documented in numerous studies: Better educated individuals are healthier than
less educated, individuals with high income are healthier than those with low
income, employees at the top end of the occupational hierarchy are healthier
than those working at the bottom end of the hierarchy, and wealthy individuals
are healthier than poor individuals. The relationship is so ubiquitous that is
often simply referred to as ‘the’ gradient (Deaton, 2003).
In this paper, we aim at contributing to the growing literature on cross-
national comparisons of the gradient. Combining data from the US Health and
Retirement Study (HRS) 2002, the English Longitudinal Study of Ageing
(ELSA) 2002 and the Survey of Health, Ageing and Retirement in Europe
(SHARE) 2004, this paper compares socio-economic inequality in physical
health across 11 European countries and the United States. In contrast to the
more recent comparative literature on socio-economic inequalities in health (e.g.
n
University of Mannheim
Scottish Journal of Political Economy, Vol. 56, No. 3, July 2009
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Journal compilation r2009 Scottish Economic Society. Published by Blackwell Publishing Ltd,
9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main St, Malden, MA, 02148, USA
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Van Doorslaer et al., 1997; Van Doorslaer & Koolman, 2004), we study
education-related inequalities. We deviate from common practice for several
reasons. First, education is arguably the most important correlate of health
(conditional on age). The partial effects of income and occupation are often
found to be much weaker than those of education (Grossman & Kaestner, 1997;
Grossman, 2005). Hence, we expect education-related inequalities in health to be
larger than income-related inequalities. Second, theoretically, the economic
literature has identified causal effects of education on health through at least
three plausible channels: (a) education raises efficiency in health production
(raises the marginal productivity of inputs), i.e. it increases an individuals
productive efficiency; (b) education changes inputs into health production
(through information) and thereby increases allocative efficiency; (c) education
itself changes time preference (and thus inputs into health production) because
schooling focuses students’ attention on the future (Becker & Mulligan, 1997).
Third, among the components of socio-economic status (education, income, and
occupation), education seems to be the one that – in the long run – is most
amenable to public policy interventions. The correlation between income (or
wealth) and health seems to suggests that income redistribution is a key measure
to decrease health inequalities. Another (still controversial) argument for income
redistribution arises if the scale of inequality itself in a country is a determinant
of population health (e.g. Wilkinson & Pickett, 2006). However, as noted by
Deaton (2002), it is important to frame policy in terms of health and wealth
simultaneously. Improving one at the expense of the other involves a difficult
and probably unnecessary trade-off. One possible policy instrument for
simultaneously improving health and wealth is education. If education improves
both wealth and health simultaneously, giving people access to more and better
education will be more successful than redistributing income or expanding
public health care expenditures.
A causal analysis of the effects of education is beyond the scope of the present
paper. Education is most likely an endogenous variable, for instance because
unobserved variables such as time preferences possibly drive both education and
health behaviour decisions, or because health (at younger ages) affects education
achievement (reverse causation). In fact, there is a growing literature trying to
identify the causal effect of education on health (recent work includes Adams,
2002; Arendt, 2005 or Lleras-Muney, 2005). This literature uses natural
experiments such as exogenous changes in compulsory schooling laws. If taken
seriously, estimating causal effects in 12 countries would mean finding natural
experiments for no less than 12 countries and finding suitable survey data to
exploit these natural experiments. Mostly, very large sample sizes are needed
because identification often relies on discontinuities around which substantial
numbers of observations are needed. To our knowledge, none of the comparable
literature in this field (cross-national comparison of health inequalities) actually
attempts this.
Rather, our modest aim is to complement the recent descriptive literature on
socio-economic inequalities in health by combining a new comparative
European data set with comparable US data. We thus broaden the geographic
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