Vortragssitzung
Social economic Inequalities and Health
Vorträge
Health Care Rationing, Sick Pay, and the Socioeconomic Health Gradient
Johannes Schünemann, Georg-August-Universität Göttingen
Einleitung / Introduction
There are substantial differences in life expectancy and morbitity across population groups stratified by education, occupation, and income. Growing health expenditure shares as a fraction of national income in many advanced countries do not seem to reduce such distributional disparities. They rather put pressure on public health systems to ration health care. Health care rationing manifests itself in long waiting times for specialist consultations and specialist assessment of health issues, non-coverage by health insurance of pharmaceutical treatment costs despite cost-efficiency, insufficient intensive care facilities and shortage of hospital beds, and restrictions of treatment time in long-term care facilities that potentially undermine patient safety. As high-income earners have more means than low-income earners to substitute for rationed access by supplementing curative health expenditure, health care rationing potentially enhances the socio-economic health gradient. It has been documented, for instance, that waiting times are typically longer for low-income patients. Health care rationing also has a feedback effect on income because it prolongs, ceteris paribus, the time being ill and sick absence from work. The extent of the effect on income depends on the generosity of sick pay in the health system, an institution that is prevalent in most OECD and G20 countries, with the excepion of the U.S. and South Korea. The income effect of illness also has an implication on health expenditure that prevents the development of health deficits, which, in turn, determines the probability of becoming sick and absent from work in the future.
Methode / Method
This paper examines the effects of health care rationing and sick pay on the socioeconomic health gradient and welfare in a calibrated multi-period overlapping generations model with stochastic survival. In line with modern gerontology research, survival probabilities depend on accumulated health deficits. We advance the health deficit approach in two directions. First, we capture the dynamic interaction between health deficits and the event of illness. Second, we distinguish between curative health care that reduces average sick time of individuals and preventive health care that slows down the acquisition of bodily impairments and thereby reduces the risk of illness.
Ergebnisse / Results
Individuals can respond to rationing of curative care in health systems by adjusting private expenses for preventive and curative care. We show that these substitution effects substantially raise differences in longevity, morbidity and welfare between income groups. By contrast, more generous sick pay significantly reduces the socioeconomic health gradient and welfare differences.
AutorInnen
Volker Grossmann, University of Fribourg
Holger Strulik, Georg-August-Universität Göttingen
Age-specific effects of the COVID-19 pandemic on income- related health inequalities in Germany
Laura Nübler, TU Berlin
Einleitung / Introduction
The COVID-19 pandemic has been shown to exacerbate income-related inequalities, and may have disproportionately impacted the mental and physical health of different income groups, age groups and genders. We analyze how the COVID19-pandemic has affected short- term trends in income-related health inequality in Germany for these different demographics.
Methode / Method
We use a varying concentration index approach based on a non-parametric smoothing technique to derive age-specific inequality estimators. We use self-reported measures of mental and physical health-related quality of life from the SF-12, self-reported health status, and reported diagnoses as proxies for physical and mental health from the German Socio-Economic Panel for the years 2018-2020.
Ergebnisse / Results
Preliminary results show that both before and during the pandemic, income-related physical health inequalities increased from the ages 20-60, and then began to decline among the elderly population. We also observe a further growth in inequality from 2018 to 2020, especially among the working age population. While both young men and women (20-40) experienced increases in physical health inequalities over this time period, the effects differ by gender for older ages: a further increase in inequality from 2018 to 2020 was also observed among women aged 40-60, but not among men of the same age group. In terms of mental health, the age-specific effects appear less systematic. Further, the levels of income-related mental health inequality do not appear to have increased between 2018 and 2020.
Zusammenfassung / Conclusion
The COVID-19 pandemic appears to have exacerbated the already existing income-related inequalities in physical health among the working-age population, especially among women, suggesting that lower income groups were disproportionately affected. However, the mental health impacts of the COVID-19 pandemic appear to have been less systematic, as income-related mental health inequalities were not shown to increase from 2018 to 2020. Further decomposition of these results into mobility indexes will be used to investigate to what extent these changes in inequality were driven by income-losses among those in poorer health, and to what extent they were driven by adverse health impacts on poorer income groups.
AutorInnen
Martin Siegel, TU Berlin
Socio-Economic Inequality in Healthcare Utilization: Evidence from Health Shocks
Felix Glaser, Johannes Kepler University Linz
Einleitung / Introduction
Health equality is an essential objective in public healthcare systems. Yet one observes substantial socio-economic inequality in the utilization of healthcare services. Understanding the determinants behind this inequality is therefore critical to enhancing health equality in our societies. In this paper, we analyze the SES gradient in healthcare utilization after suffering a health shock by decomposing the raw gap into health demand and health supply factors.
Methode / Method
We use high-quality administrative health register data for the entire population in Upper Austria, providing detailed information on hospitalizations including diagnoses, length of stay, treatments, departments and readmissions. Subsequently, we follow patients on their pathway through the healthcare system by utilizing information on the outpatient sector and prescriptions for medication. We compare patients with high and low SES who are otherwise identical in important individual characteristics, diagnosed disease, within-hospital treatment, prior health status and health behavior, the timing of hospitalization as well as hospital and GP fixed effects.
Ergebnisse / Results
Overall, we find that the raw socio-economic differences are reduced substantially by up to 50 percent once accounted for individual characteristics, time trends and the exact diagnosis. Accounting for health status and health behavior prior to the health shock further reduces the SES gap and even eliminates the difference entirely for certain components of healthcare utilization. Among cancer diagnoses we find significantly shorter hospital stays for high-SES patients but no differences in the number of services, short-term mortality and readmissions once controlling for prior health status and behavior. This indicates that for a given diagnosis, hospitals do not treat cancer patients differently according to their socio-economic status. However, the SES gradient widens after patients leave the hospital. High-SES patients reduce the number of medication prescriptions and are more likely to consult specialist doctors rather than GPs. Mortality significantly increases for low-SES patients and the gap widens over time. For cardiovascular diseases we do not find an SES gradient during the initial hospitalization and doctor-visiting behavior, although high-SES patients tend to improve their health status more and reduce their drug prescriptions.
Zusammenfassung / Conclusion
We estimate the socio-economic gradient in healthcare utilization during and after hospitalization. Our results indicate that after suffering a health shock, there is no evidence for an SES health supply gradient. However, differential health behaviors are reinforced after the shock. High-SES patients tend to benefit from their overall better health status, leading to better long-term health outcomes.
AutorInnen
Wolfgang Frimmel, Johannes Kepler University Linz
Felix Glaser, Johannes Kepler University Linz
Excess costs of gender incongruence and gender dysphoria in Germany
Thomas Grochtdreis, Universitätsklinikum Hamburg-Eppendorf
Einleitung / Introduction
Gender incongruence or gender dysphoria (GIC/GD) are among the rare clinical conditions. For transgender and gender diverse (TGD) people, it is known that there is a lack of health care practitioners with experience in trans health care. This may result in either inadequate provision of health care or in an increased seeking for adequate trans health care. Not much is generally known about the health care services utilization and the resulting costs in TGD people with GIC/GD. Therefore, the aim of this study was to determine the excess costs caused by treatment-seeking TGD people with GIC/GD in Germany.
Methode / Method
Baseline data of a randomized-controlled trial with a sample of treatment-seeking TGD people with GIC/GD (n = 167) were combined with data of a telephone survey conducted in a representative sample of the general German population (n = 2314). The data sets were matched using entropy balancing and analyzed from a societal perspective. Six-month excess costs were calculated for the year 2020 using two-part models with logit specification for the first part and a generalized linear model from the gamma family with a log link function for the second part.
Ergebnisse / Results
The total six-month excess costs of GIC/GD from societal perspective were 1221 € (95% CI: −315 € to 2757 €). The direct excess costs were 211 € (95% CI: −871 € to 1294 €) and the indirect excess costs due to absenteeism from work were 1010 € (95 % CI: 125 € to 1895 €). The total excess costs of trans men, trans women and non-binary people were 1180 € (95% CI: −918 € to 3278 €), 1350 € (95% CI: −1012 € to 3712 €) and 1630 € (95% CI: −2078 € to 5339 €), respectively.
Zusammenfassung / Conclusion
The total six-month excess costs caused by treatment-seeking TGD people with GIC/GD were not statistically significantly different compared to the costs caused by the general German population. However, indirect excess costs due to absenteeism from work were statistically significantly higher. Potential causes of absenteeism from work, such as experienced or expected discrimination, need to be identified and addressed so that TGD people can experience a healthy work environment without being stigmatized as TGD.