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International Journal for Equity in Health
Published in: International Journal for Equity in Health 1/2015

Open Access 01-12-2015 | Research

Unexplained health inequality – is it unfair?

Authors: Yukiko Asada, Jeremiah Hurley, Ole Frithjof Norheim, Mira Johri

Published in: International Journal for Equity in Health | Issue 1/2015

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Abstract

Introduction

Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health – a difference in health – is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question – whether unexplained health inequality is unfair – determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity.

Methods

We use the American sample of the 2002–03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity.

Results

Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable).

Conclusions

The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations.
Appendix
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Literature
1.
Truman BI, Smith KC, Roy K, Chen Z, Moonesinghe R, Zhu J, et al. Rationale for regular reporting on health disparities and inequalities - United States. MMWR Surveill Summ. 2011;60 Suppl 01:3–10.PubMed
2.
3.
4.
Asada Y. Health inequality: Morality and measurement. Toronto: University of Toronto Press; 2007.
5.
Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167–94.PubMedCrossRef
6.
7.
8.
Jusot F, Tubeuf S, Trannoy A. Circumstances and efforts: how important is their correlation for the measurement of inequality of opportunity in health? Health Econ. 2013;22:1470–95.PubMedCrossRef
9.
Rosa Dias P. Inequality of opportunity in health: evidence from a UK cohort study. Health Econ. 2009;18:1057–74.PubMedCrossRef
10.
Trannoy A, Tubeuf S, Jusot F, Devaux M. Inequality of opportunities in health in France: a first pass. Health Econ. 2009;19:921–38.CrossRef
11.
Fleurbaey M, Schokkaert E. Unfair inequalities in health and health care. J Health Econ. 2009;28:73–90.PubMedCrossRef
12.
Fleurbaey M, Schokkaert E. Equity in health and health care. In: Pauly MV, Mcguire GG, Barros PP, editors. Handbook of Health Economics, vol. 2. Oxford: Elseview BV; 2012. p. 1003–92.
13.
Statistics Canada,United States National Center for Health Statistics. Joint Canada/United States Survey of Health: public use microdata file user guide. Ottawa: Statistics Canada; 2004.
14.
15.
O'Donnell O, van Doorslaer E, Wagstaff A, Lindelow M. Analyzing health equity using household survey data: A guide to techniques and their implementation. New York: The World Bank; 2007.CrossRef
16.
17.
Drummond M. Introducing economic and quality of life measurements into clinical studies. Ann Med. 2001;33:344–9.PubMedCrossRef
18.
Samsa G, Edelman D, Rothman ML, Williams GR, Lipscomb J, Matchar D. Determining clinically important differences in health status measures. Pharmacoeconomics. 1999;15:141–55.PubMedCrossRef
19.
Chen C-N, Tsaur T-W, Rhai T-S. The Gini coefficient and negative income. Oxf Econ Pap. 1982;34:473–8.
20.
21.
22.
Atkinson AB. Health inequality, health inequity and health spending. In: Eyal N, Hurst S, Norheim OF, Wikler D, editors. Inequalities in health: concepts, measures, and ethics. New York: Oxford University Press; 2013. p. 27–36.CrossRef
23.
Huang IC, Frangakis C, Atkinson MJ, Willke RJ, Leite WL, Vogel WB, et al. Addressing ceiling effects in health status measures: a comparison of techniques applied to measures for people with HIV disease. Health Serv Res. 2008;43:327–39.PubMedCentralPubMedCrossRef
24.
Li L, Fu AZ. Some methodological issues with the analysis of preference-based EQ-5D index score. Health Serv Outcomes Res Methodol. 2009;9:162–76.CrossRef
25.
Pullenayegum EM, Tarride JE, Xie F, Goeree R, Gerstein HC, O'Reilly D. Analysis of health utility data when some subjects attain the upper bound of 1: are Tobit and CLAD models appropriate? Value Health. 2010;13:487–94.PubMedCrossRef
26.
Sullivan PW, Ghushchyan V. Mapping the EQ-5D index from the SF-12: US general population preferences in a nationally representative sample. Med Decis Making. 2006;26:401–9.PubMedCentralPubMedCrossRef
27.
28.
StataCorp. Stata statistical software: release 11.0. College Station, Texas: Stata Corporation; 2009.
29.
30.
McGrail KM, van Doorslaer E, Ross NA, Sanmartin C. Income-related health inequalities in Canada and the United States: a decomposition analysis. Am J Public Health. 2009;99:1856–63.PubMedCentralPubMedCrossRef
31.
Gordis L. Epidemiology. Philadelphia: W.B. Saunders Company; 1996.
32.
Cappelen AW, Norheim OF, Tungodden B. Genomics and equal opportunity ethics. J Med Ethics. 2008;34:361–4.PubMedCrossRef
33.
Dworkin R. What is equality? Part 1: Equality of welfare. Philosophy Public Affairs. 1981;10:185–246.
34.
Dworkin R. What is equality? Part 2: Equality of resources. Philosophy Public Affairs. 1981;10:283–345.
35.
Hausman D. Egalitarian critiques of health inequalities. In: Eyal N, Hurst S, Norheim OF, Wikler D, editors. Inequalities in health: concepts, measures, and ethics. New York: Oxford University Press; 2013. p. 95–112.CrossRef
36.
Marmot M. Fair society, healthy lives. In: Eyal N, Hurst S, Norheim OF, Wikler D, editors. Inequalities in health: concepts, measures, and ethics. New York: Oxford University Press; 2013. p. 282–98.CrossRef
37.
Segall S. Health, luck, and justice. Princeton: Princeton University Press; 2010.
38.
39.
Bago d'Uva T, Jones AM, van Doorslaer E. Measurement of horizontal inequity in health care utilisation using European panel data. J Health Econ. 2009;28:280–9.PubMedCrossRef
40.
Deaton A. What does the empirical evidence tell us about the injustice of health inequalities? In: Eyal N, Hurst S, Norheim OF, Wikler D, editors. Inequalities in health: concepts, measures, and ethics. New York: Oxford University Press; 2013. p. 263–381.CrossRef
41.
Temkin L. Rethinking the good: moral ideals and the nature of practical reasoning. New York: Oxford University Press; 2013.
42.
Lefranc A, Pistolesi N, Trannoy A. Equality of opportunity and luck: Definitions and testable conditions, with an application to income in France. J Public Econ. 2009;93:1189–207.CrossRef
Metadata
Title
Unexplained health inequality – is it unfair?
Authors
Yukiko Asada
Jeremiah Hurley
Ole Frithjof Norheim
Mira Johri
Publication date
01-12-2015
Publisher
BioMed Central
Published in
International Journal for Equity in Health / Issue 1/2015
Electronic ISSN: 1475-9276
DOI
https://doi.org/10.1186/s12939-015-0138-2

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