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July 11, 2007


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Lots of wonderful stuff here: a different perspective, important facts, references, etc. Thanks.

These are all very interesting points, and I agree on the broad theme. But I think that larger efforts toward equality are on the backburner for the types of reasons Westmoreland gives in his budget article, and I think the expansion of extant entitlements may be the only political option left.

(I admit that focus on this goal probably distracts fro m the more useful goals you mention. Larry Solum's "Constitutional Possibilities" is interesting on this score--should one seek a "comprehensive solution" that is very unlikely or tinker with a higher likelihood of success?)

I also wonder about the degree to which things like SES and health entitlements can be disentangled. Isn't the guarantee of healthcare to someone a way of raising their SES? Certainly a low-income worker is going to feel less anxiety, and more valued as a member of society, if he is assured that society won't just let him die of a condition that could be treated for tens of thousands of dollars.

Hey Frank,

Oh, I agree that as a pragmatic matter, we aren't going to be getting any closer to redistributing income any time soon.

But you do raise an important question, and it is a very serious problem, indeed. Namely, if the social epidemiologists are right and the single most important factor in health and disease is SES, "tinkering" with other measures virtually guarantees that progress -- if it occurs at all -- will be incremental.

OTOH, if we cannot pragmatically reduce SES, then should we simply flog the dead horse instead of trying to at least make incremental progress?

This, I submit, is the paradox of ethics and health policy, one I touch open in my latest paper, actually.

My crude response is that there many things we can do to ameliorate social conditions that do not involve redistribution of wealth. At least we can begin by changing the 19:1 ratio of health care spending. There is no excuse, IMO, for our current imbalanced approach to health.

You're also right to point out the problems in assessing SES, which the social epidemiologists admit is one of the limitations of their theory. While health entitlements and SES are not totally independent variables, I also tend to think that guaranteeing access to care would not, in aggregate, have a really significant effect on raising SES.

I guess what I mean on that point is that the Whitehall studies in the UK -- where access to care is guaranteed -- displayed just such a robust socioeconomic gradient of health. This is partly what Sreenivasan is pointing out in his essay on the social epidemiologists' point. Daniels uses this data as a justification for universal health care. Sreenivasan's argument is that by their own data, efforts would (in theory) be better directed to reducing income inequality, seeing as how universal health care doesn't seem to affect the gradient all that much.

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