Wednesday, October 25, 2017

Herrnstein & Murray are still right  -- and very relevant to the healthcare debate

The poor die young.  That is the simplest summary of the latest study looking at the association between wealth and health.  Whenever it is examined, a correlation between social class and health seems to emerge.  The findings surveyed  by Hernstein and Murray are the best known evidence of that but Herrnstein & Murray wrote over two decades ago so it is interesting to see that nothing has changed. Herrnstein died about the time the book was released so was spared the torrent of abuse that was poured out on the scholarly head of Charles Murray when his findings became known.  He survived the onslsaught however and is still making waves.  The attack on him at Middlebury college got a lot of press recently.

There is however a certain vagueness about what you call social class and there are distinct differences between Britain and America in that regard.  And although its importance to social class is generally accepted, wealth is rarely examined in medical research. It is usually considered to be "too sensitive"  for questions about it to be included in surveys.  So the findings below are valuable in filling a gap. The article is titled: "Wealth-Associated Disparities in Death and Disability in the United States and England" and it appeared in JAMA, a leading medical journal.

It will be interesting to see what, if any, reaction the article gets.  It is unlikely that the authors will receive the abuse that was heaped on Charles Murray.  After the first decade or so of huffing and puffing, the Left seem to have bowed to reality.  Mention of class effects on health are these days normally addressed, if at all, as just another example of injustice.  What was once seen as a politically incorrect attack on the poor is now usually seen as an argument for helping the poor in various ways.  The Left ended up assimilating the effect into their "social justice" narrative.

And what cure do the Left advocate for this injustice?  Easy! Single payer health-insurance.  It was one of the arguments behind the agony of Obamacare.  And that makes the study below of exceptional interest -- because it compared American health results with results from a country that has had single-payer healthcare for a very long time: England.  So the poor should do much better in England?  Right?  Wrong!  The wealth effect was similar in both countries.  So this study is exceptionally relevant to one of the most important issues in American politics today.

Academic prose is normally too dense for non-academics to make much out of it but the place where you are most likely to find plain speaking is the set of "Conclusions" at the end of the article.  So let me reproduce in full the "Conclusions" of the present article:

"We found that lower wealth was associated with higher mortality and disability in older adults in both the United States and England. This relationship was apparent from age 54 years and continued into later life. This study found no evidence that providing state-sponsored health insurance from birth (England), or providing state-sponsored health insurance later in life (United States), eliminated wealth-associated health disparities. Our study suggests that policy makers interested in decreasing mortality and function disparities in older adults should take a broad view and consider interventions beyond providing access to health care."

So there was effectively no difference between America and England in health outcomes, including death.  The poor get sicker and die younger in both countries at roughly the same rate.  So the authors are in fact shooting down one of the important talking points of the Left. What they mean by "interventions beyond providing access to health care" is to make the poor richer.  They wisely don't go in to how you achieve that, though. So this is an article of unusual political importance. 

It also has important implications for medical research generally. Probably because of political correctness, epidemiological research in particular simply ignores social class.  If it is mentioned at all, the only index of it used is education.  But my research showed long ago that education misses a lot. You can have highly educated poor people (e.g. the iconic Ph.Ds doing burger flipping in McDonalds) to dropouts making billions (e.g. Bill Gates).  You really do need to examine wealth directly.

But medical researchers just don't do that most of the time. And that very often makes the significance of their findings moot.  If, for instance, you find that big drinkers of pop die young, a medical researcher would normally conclude that pop kills you. They are that stupid. If you happen to know that the poor drink more pop, however, you can say (and I have often said it) that the conclusion is nonsense. If wealth had been included in the analysis, you will probably find that the "effect" of pop on health was in fact the effect of wealth discrepancies.

So I suppose it is a lot to ask for but one hopes that future medical researchers might use the article below to make some mention of what their research was not able to examine.

The authors below do not venture into much consideration of WHY the poor die young but do mention various environmental stressors.  I would add however that genetic influences are at work too. IQ is a much neglected index of social class.  The rich are smarter. The old challenge, "if you are smart, how come you are not rich?, has much justice to it. We can probably all think of exceptions but higher IQ does help you to figure out ways of making money.

Wealth-Associated Disparities in Death and Disability in the United States and England

Lena K. Makaroun et al.


Importance:  Low income has been associated with poor health outcomes. Owing to retirement, wealth may be a better marker of financial resources among older adults.

Objective:  To determine the association of wealth with mortality and disability among older adults in the United States and England.

Design, Setting, and Participants:  The US Health and Retirement Study (HRS) and English Longitudinal Study of Aging (ELSA) are nationally representative cohorts of community-dwelling older adults. We examined 12 173 participants enrolled in HRS and 7599 enrolled in ELSA in 2002. Analyses were stratified by age (54-64 years vs 66-76 years) because many safety-net programs commence around age 65 years. Participants were followed until 2012 for mortality and disability.

Exposures:  Wealth quintile, based on total net worth in 2002.

Main Outcomes and Measures:  Mortality and disability, defined as difficulty performing an activity of daily living.

Results:  A total of 6233 US respondents and 4325 English respondents aged 54 to 64 years (younger cohort) and 5940 US respondents and 3274 English respondents aged 66 to 76 years (older cohort) were analyzed for the mortality outcome. Slightly over half of respondents were women (HRS: 6570, 54%; ELSA: 3974, 52%). A higher proportion of respondents from HRS were nonwhite compared with ELSA in both the younger (14% vs 3%) and the older (13% vs 3%) age cohorts. We found increased risk of death and disability as wealth decreased.

In the United States, participants aged 54 to 64 years in the lowest wealth quintile (Q1) (≤$39 000) had a 17% mortality risk and 48% disability risk over 10 years, whereas in the highest wealth quintile (Q5) (>$560 000) participants had a 5% mortality risk and 15% disability risk (mortality hazard ratio [HR], 3.3; 95% CI, 2.0-5.6; P < .001; disability subhazard ratio [sHR], 4.0; 95% CI, 2.9-5.6; P < .001).

In England, participants aged 54 to 64 years in Q1 (≤£34,000) had a 16% mortality risk and 42% disability risk over 10 years, whereas Q5 participants (>£310,550) had a 4% mortality risk and 17% disability risk (mortality HR, 4.4; 95% CI, 2.7-7.0; P < .001; disability sHR, 3.0; 95% CI, 2.1-4.2; P < .001). In 66- to 76-year-old participants, the absolute risks of mortality and disability were higher, but risk gradients across wealth quintiles were similar. When adjusted for sex, age, race, income, and education, HR for mortality and sHR for disability were attenuated but remained statistically significant.

Conclusions and Relevance:  Low wealth was associated with death and disability in both the United States and England. This relationship was apparent from age 54 years and continued into later life. Access to health care may not attenuate wealth-associated disparities in older adults.


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