Beckfield et al (2015) Flashcards
How do welfare systems impact healthcare?
- in its narrow definition as the state’s role in education, health, housing, poor relief, social insurance and other social services, the welfare state clearly plays a key role as mediator in the influence of the material and social determinants of health and health inequalities. This is most obvious in terms of the strong relationship between universal health-care systems, higher levels of health-care decommodification (Bambra, 2005), better population health and lower health inequalities
- the welfare state sets the parameters in which the social determinants of health occur.
- the way in which the welfare state distributes financial resources and welfare services has consequences for social and economic hierarchies.
Outline the different types of welfare state regimes
Liberal (minimal state welfare, heavy reliance on the private sector, for example, the United Kingdom, the United States); Conservative (status differentiating welfare, high role for employers); and Social Democratic (encompassing, generous, equalising benefits)
What types of health outcomes differ depending on type of welfare state regime?
The general pattern found by epidemiological studies that have analysed cross- national differences in population health between different types of welfare state is that infant mortality rates (IMR) vary significantly by welfare regime type, with rates lowest in the Social Democratic Scandinavian countries and highest in the Liberal ones. For example, Chung and Muntaner’s (2006) multilevel longitudinal analysis of welfare state regimes found that around 20 per cent of the difference in IMR between countries, and 10 per cent for low birth weight (LBW), could be explained by the type of welfare state. Social Democratic countries had significantly lower IMR and LBW rates, compared with all other welfare state regimes.
Existing theories of the social determinants of health led to an expectation that this high performance of the more encompassing welfare states in terms of general population health would also be reflected in terms of smaller health inequalities within these countries.
What do materialist, Cultural-behavioural and psychosocial theories posit about social determinants of health?
Materialist theory emphasizes income: social inequalities in health would mainly arise because groups with higher incomes are better able to afford access to goods and services that are conducive to good health (for example, health care, housing and healthy food)
Cultural-behavioural theory stresses that the relationship between social factors and health is mainly a consequence of social differences in health behaviour (for example, in most countries, smoking and unhealthy diets are more prevalent in the lower socio-economic strata). Inequalities in health behaviour would mainly be a result of cultural acceptance of health damaging behaviour in the lower social groups.
Psychosocial theories focus on the emotional feelings and physical stress response that result from being exposed to social inequality and social exclusion. Rather than through the availability of material resources or cultural acceptance, social inequality would be associated with health through the presence of a social hierarchy as such. Social inequality creates relative differences between groups, which would lead to feelings of inferiority and subordination and ultimately to physical and mental stress responses.
What theory does Beckfield et al (2015) propose?
We propose broadening these theoretical developments to a wider range of stratified goods, including the many elements of socio-economic position. That is, this developing institutional theory holds that inequality in some variable Y can be explained in part by institutional factors that
(i) shift Y from people who have more Y to people who have less Y (or vice versa, through regressive taxation),
(ii) limit how low or high Y can go for different population groups or
(iii) affect other variables such as X that themselves affect Y and its distribution.
We argue that these institutional mechanisms are helpful in thinking not only about the distribution of health, but also the distribution of the social determinants of health.
These three institutional mechanisms – redistribution, compression and mediation – identify how an institutional theory of health inequality can be developed. In European welfare states, the reason social inequalities in health are surprising is that health care has long been considered and delivered as a citizenship right as have other areas of social provision such as income support for the unemployed. At least for citizens, then (the picture is more complicated if we include non-citizen migrants), the redistribution (for example, income redistribution as an institutional effect on one of the social determinants of health), compression and mediation channels from institutions to inequality should be working to reduce health inequality. That is, welfare states set a minimum bound for the healthcare of citizens (compression, which happens in part as regulations of health-care access) and they limit inequality in some of the factors that have been established as robust social determinants of health, such as income (mediation).
We take the complexity of population health distribution in institutional context as an invitation to theoretical development. Any measure of health inequality is a snapshot, taken at one moment in the evolution of a population, that compares the health of one socially defined category of people to another. For instance, women aged 45–64 with a university degree could be compared with same-aged women with a lower level of educational attainment than a university degree, on the common metric of a depression scale, blood pressure or mortality risk over a defined period. An institutional theory explains this health inequality as a function of redistribution (shifting social determinants of health like income and wealth), compression (institutional arrangements that provide health care directly, thereby lowering rates of the most common illnesses for this group) and mediation (institutional arrangements that reduce educational inequality). These effects can be reinforcing, but they can also be cross-cutting.
What are theoretical challenges to exploring effects of welfare systems on health?
This example illustrates well the theoretical complexity in understanding how health inequalities respond to institutions. Illnesses vary greatly in aetiologic period, with some like heart disease emerging over decades, and others like depression emerging quickly in response to disruption. Populations evolve over time, as people are born, migrate and die. People carry with them early-life conditions, such that an educational system in early adulthood determines educational inequality throughout the lifecourse. At the same time, institutions change, sometimes slower than bodies, but sometimes faster (Streeck and Thelen, 2005). People within a population at any one time have therefore potentially experiences with different welfare state lifecourses (Bambra et al, 2010). A key innovation we propose is that insights from the extensive literature on the lifecourse should be synthesized with social epidemiological knowledge about disease aetiology, and comparative-historical evidence on institutional change (Hall and Taylor, 1996; Korpi and Palme, 1998; Kangas and Palme, 2007)
Another theoretical challenge that arises in the case of health inequality – in part because welfare state institutions have direct and indirect effects on health – is the potential of cross-cutting or amplifying institutional effects across institu- tional domains. That is, welfare states can stratify health through health care, and, simultaneously, through the distribution of other valued goods that themselves operate as social determinants of health (such as employment security and precarity). With respect to inequalities in mortality, the institutional effect of health-care institutions may be restricted to amenable mortality (Nolte and McKee) while other welfare state institutions through their impact on social determinants of health also effect inequalities in mortality that are not directly affected by the health-care system. We conceptualize this simultaneous operation of institutions in multiple domains at multiple levels as institutional imbrication (the concept of imbrication draws on Sassen’s work on globalization). Institutional imbrication is the overlapping of two or more institutions, such as when the educational system distributes resources that are themselves important within the health-care system. For instance, a highly stratified educational system would amplify health inequality in situations where complex treatment regimes produce strong educational gradients in health care. Imbrication allows for amplifying, cross-cutting or moderating effects of institutional arrangements, accurately reflecting the reality that people live more than one policy at a time over the life course
What do policy-makers miss if they only target the financial dimension of disadvantage?
Note that this perspective would take into account the role of multiple disadvantage to explain the persistence of social inequalities in health in welfare states. By mostly targeting the financial dimension of disadvantage, welfare states may have neglected that financial adversity is often paralleled by other dimensions of disadvantage (Weber, 2006). People who are most in need of financial compensation by the welfare state also have lower educational levels, less social support and smaller social networks. In addition, financial disadvan- tage is found more among social groups that face discrimination and social exclusion, such as women (especially lone mothers) and ethnic minorities (Raphael and Bryant, 2004). This connects to Sen’s (1999) capability approach. This general framework states that people will only be able to translate endowments (such as sufficient financial means) into capabilities (such as the capability to pursue a healthy life) if they possess sufficient so-called ‘conversion factors’ (for example, cognitive or social resources). On the basis of this general framework, we suggest that people are only able to turn the financial compensa- tion and other incentives provided by the welfare state into health benefits if they have the right resources (private household or public welfare) at their disposal to do so (Bartley, 2003).
How can socioeconomic factors determine how well individuals can benefit from social policy?
We emphasize that these resources may be located both at personal or social and societal levels. For example, at the personal level, people will benefit more from welfare arrangements if their educational level is higher (for example, because of better knowledge on how to make adequate use of health-care services provided by the welfare state). At the societal level, social norms may facilitate the use of welfare arrangements by disadvantaged groups (for example, in societies with norms that are positive towards working women, lone mothers will be more prone to use subsidized child-care arrangements offered by the welfare state). Turning to the institutional level, the specific institutional arrangements determine whether welfare beneficiaries can use their higher educational status for choosing child care, health care or other welfare arrange- ments or not
What are negative health impacts of unemployment?
The negative health experiences of unemployment are not limited to the unemployed only but also extend to families and the wider community. Links between unemployment and poorer health have conventionally been explained through two inter-related concepts: the material consequences of unemployment (for example, wage loss and resulting changes in access to essential goods and services) and the psychosocial effects of unemployment (for example, stigma, isolation and loss of self-worth). Lower socio-economic classes are disproportionately at risk of unemployment and it is a key determinant of the social gradient in health. Health-related worklessness is also concentrated in more deprived areas and among less skilled workers. Again, our theoretical approach suggests that the health effects of unemployment should be dampened in places where the welfare state provides public resources that can substitute for the loss of private household resources.
Social protection (particularly wage replacement rates) during unemployment varies by welfare state regime. To a large degree this reflects the historical influence of differing political traditions, with those countries experiencing more post-war years of Social Democratic rule providing more generous systems of support (Esping-Andersen, 1990). In essence, there are three interrelating principles underpinning provision: universalism, social insurance and means- testing (Diderichsen, 2002). Systems based on universal provision do not make reference to previous contributions or means-testing and are offered to all citizens on an entitlement basis as long as specific demographic, social or health criteria are fulfilled. Often flat-rate benefits are paid. Under social insurance systems, entitlement to benefits is dependent on previous contributions and in most cases subsequent benefit levels reflect previous earned income. Under means-testing, entitlement is restricted on the basis of income and the (often minimal) financial support is targeted at those in most need, usually after they have exhausted all other means (for example, personal savings or social insurance) (Korpi and Palme, 1998). Attention to the health-distributing effects of these varying institutional designs would contribute to the development of our theoretical approach.
How can welfare combat the detrimental health effects of unemployment?
For instance, the role of imbrication (overlap) can be specified by considering how unemployment protection mixes policy principles of universalism and means-testing. There are also clear differences by welfare state regime – due to the influence of differing political traditions – in terms of how these principles are put into practice, particularly in terms of the generosity of benefits paid to the unemployed (replacement rates), the qualifying period and conditions, duration of benefit payments and the waiting period before entitlement is activated. In each of these respects, the Scandinavian welfare states are generally more generous than the other welfare state regimes, particularly in comparison to the Liberal regime. Differences in the social protection offered to the unemployed could therefore be an important mediatory factor in the relationship between poverty, unemployment and health especially since employment-based inequal- ity in health should depend on three factors: the level of unemployment, the age structures of the employed and unemployed populations, and the form of provision of unemployment insurance benefits
A study by Bambra and Eikemo (2009) compared the extent to which relative health inequalities between unemployed and employed people varied across 23 European countries and in terms of the different approaches to social protection taken by different European welfare state regimes (Social Democratic, Liberal, Conservative, Southern and Eastern). The study found that in all countries, unemployed people reported higher rates of poor health than those in employ- ment. There were also clear differences by welfare state regime. Relative inequalities between employed and unemployed were largest in the Liberal regime. Wage replacement rates for the unemployed are the lowest in these welfare states, and benefits are means-tested and subject to strict entitlement rules. The unemployed in the Liberal welfare states are therefore at a great financial disadvantage in comparison to those in employment and this may well explain the magnitude of inequality as financial strain has been found to be an important factor in the relationship between unemployment and ill health (Kessler et al, 1987). Furthermore, means-tested benefits are associated with stigma and so the non-financial problems of unemployment may be greater in the Liberal welfare states (Diderichsen, 2002). A comparative study by Rodriguez (2001) found that in the United Kingdom, Germany and the United States, the likelihood of reporting poor health was significantly higher among unemployed people in receipt of means-tested benefits than those in receipt of entitlement benefits. These results illustrate the compression and mediation channels of our institutional theoretical approach.
How do policies vary w regards to healthy/unhealthy food?
Access to healthy food is often restricted by what have been termed ‘obesogenic environments’: geographic areas (usually low income areas) with little access to fresh fruit and vegetables, high access to fast foods combined with low access to green space or sports facilities for exercise (Lake and Townshend, 2006). International varia- tions in access to healthy food, obesogenic environments and the naturalization of the individual as the locus of autonomous food choices (Mayes, 2014) may be important factors behind differences in the health of populations, and well illustrate the compression pathway from welfare states to the distribution of population health.
How do policies vary w regards to housing?
Housing has long been recognized as an important material determinant of health, and health concerns underpinned the slum clearances that accompanied the advent of the post-war welfare state. Damp housing can lead to breathing diseases such as asthma; infested housing leads to the rapid spread of infectious diseases; overcrowding can result in higher infection rates and is associated with an increased prevalence of household accidents. Expensive housing (for exam- ple, as a result of high rents) can also have a negative effect on health as expenditure in other areas (such as diet) is reduced (Stafford and McCarthy, 2006). Housing also illustrates how imbrication (overlap) can affect the distribu- tion of health through the social determinants, as subsidies for property development and mortgage loans generate property bubbles and counterproduc- tively high interest rates.
How can health care access vary?
In most European countries, access to health care is universal. However, there are variations in terms of how health care is funded (for example, social insurance, private insurance or general taxation), the role and level of co-payments for treatment, the role and level of prevention, the extent of provision – what has been collectively termed ‘health- care decommodification’ (Bambra, 2005), and how patients’ access to health- care providers is regulated
Provision can also vary spatially within countries, depending upon how care providers are incented to locate in deprived areas. People in lower socio- economic classes are also less likely to access health-care services than those in higher socio-economic classes with the same health need
The regulation of access to health care is one example of how the redistribution channel might operate, as the welfare state regulates and incents the location of and access to medical care and public health resources.
