By Preeti Pushpalata Zanwar and Anne M. Burton

Last year’s ASHEcon conference in Austin included a special pre-conference workshop on the economics of health equity. Topics of discussion included health disparities and health equity for different groups, including people with disabilities, LGBTQ+, and racial and ethnic minorities. The workshop was organized by Marcella Alsan, Professor of Public Policy at Harvard University; Kate Bundorf, J. Alexander McMahon Distinguished Professor of Health Policy and Management at Duke University; Kitt Carpenter, E. Bronson Ingraham University Distinguished Professor of Economics and Health Policy at Vanderbilt University; David Cutler, Otto Eckstein Professor of Applied Economics at Harvard University; Marcus Dillender, Assistant Professor of Medicine, Health, and Society at Vanderbilt University; Mónica García-Pérez, Professor of Economics at St. Cloud State University; Darrell Gaskin, William C. and Nancy F. Richardson Professor in Health Policy at Johns Hopkins University; Harold Pollack, Helen Ross Professor at the Crown Family School of Social Work, Policy, and Practice at the University of Chicago; Kosali Simon, Herman B. Wells Endowed Professor in the School of Environmental and Public Affairs at Indiana University; and David Slusky, Professor of Economics at Kansas University and Executive Director of ASHEcon. We spoke with several of the organizers and board member participants: David Cutler; Mónica García-Pérez; Ellen Meara, Professor of Health Economics and Policy at Harvard University; Harold Pollack; and Kosali Simon about the pre-conference and ways in which health economists can improve health equity.

What topics were covered at the pre-conference and what was the main focus of the event?

The Health Equity Pre-Conference was intended to build on the momentum of earlier Health Equity workshops to give participants the chance to discuss important research questions, available data sources and gaps in data, as well as to interact with others with shared research interests around health equity in a space that permitted people to think about a single dimension of equity in depth (i.e., disability as a disparity population, health equity for Black Americans). It was also intended to connect researchers in person who are interested in health equity topics or curious about the idea of incorporating this perspective in their research.

What progress have we (economists, policymakers) made in improving equity within the profession, as well as health equity for different groups (race, gender, LGBTQ+, socioeconomic status, disability, etc.) over the last 30 years? Have we stalled or regressed in some areas?

I think that there has been progress in most areas – e.g., in 1999 on the job market, a serious consideration for women was whether they would be taken seriously if they wore pants, and my advisor advised me that “You don’t have to sit on the bed in a hotel room at the AEA, so be sure to ask for a chair.” I’m grateful women entering the job market can spend more energy on the content of an interview and not these issues. Still, recent focus on #MeTooEcon shows we still have a long way to go for women in economics. That said, I have found the health economics profession, which has more women than other fields, to be more supportive than other fields. I do not yet see the same gains for people of color or our LGBTQ+ colleagues, but a welcome event in Austin was a well-attended and excellent session on the economics of LGBTQ+ health.

I was delighted by the disability session. Attendees were strongly motivated to address key questions, and well-prepared to interact at our session.

In general, there has been progress in the profession of economics on topics of health equity. However, economists are still focused on the disparities perspective and have not incorporated the discussion of global goals for society. This particular discussion is important as we transform the deficit conversation (i.e., poor background explains poor outcomes) into society wellbeing goals (i.e., preventable diseases should be prevented). It is also important that ASHEcon continues to play a key role in moving forward the conversations about health equity as a serious topic of study where new methodologies and cutting-edge research is needed.

What is the comparative advantage economists have in studying health equity?

I think economists, more than other fields, tend to think about public policies as drivers of health and health equity. Important to these discussions are analyses of the unintended effects of policies. For example, tobacco taxes are one of the most important policy levers for lowering rates of smoking, but due to higher rates of smoking in low-income populations, they are regressive. Or we tend to think of the Great Migration north of African Americans as likely to improve the health of those who migrated. However, we know from the economics literature that African Americans who migrated from the south to northern cities died earlier than predicted, often due to causes related to drinking (cirrhosis) and smoking behavior (pulmonary disease), behaviors that were more common in northern cities than in the south.

I would say that the work of economists contributes the same strengths in studying health equity as we do in studying other domains: attention to incentives and to rigorous data analysis.

Economists think about the alternative explanations to issues with strong emphasis on using empirical evidence, data structure, and theory. Health equity discussions could build further strength in sound theories that allow conversations to deepen into health outcome goal settings and structural and institutional settings that are channeling these goals or creating barriers to achieve them. Further, economists are trained to look at causal mechanisms within theoretical frameworks. As we move these structures into a health equity framework, new theories could be designed to formally separate the discussion between health disparities and health equity.

What are important topics or aspects of health equity that we don’t know enough about? What is the research frontier? What policies, factors, or groups would you recommend economists interested in health equity focus on studying?

I think it’s important for researchers to move past “describing health equity” to focus on mechanisms that may improve or impede equity. There is a lot of research suggesting how policies such as banking rules and zoning may affect people’s access to jobs, education, clean air and water, and other factors likely to matter for health. But what modern policies at the local, state, or federal level have sought to ameliorate these disparities and how have they affected the health of groups marginalized along different dimensions? How do immigration policies in the U.S. impede or improve the health of families born outside the U.S.? What local or state policy environments are more likely to protect the health of LGBTQ+ populations?

Within the disability space, I would say one frontier would be the incorporation of rigorous quality-of-life assessment in ways that do not disvalue the lives of people who live with disabilities. Another frontier would be the incorporation of behavioral economics and the role of administrative burdens within empirical and policy models of public programs. As discussed at the conference, these behavioral-economic factors and administrative burdens can create avoidable intersectional inequalities within the population of people with disabilities who interact with Medicaid, SSI, and other public assistance programs.

The new frontiers are new theory and new evidence. The Economics of Health Equity probably needs a grounding base similar to the theory of Welfare Economics. As we look at these theories of equity, we can evaluate health in the framework of fairness and fair allocation of resources (Fleurbaey 2006).

How did the pre-conference continue or expand on the work of the Economics of Health Equity Interest Group?

The two dovetail. The conference expanded on the work of the Economics of Health Equity interest group, but also gave more focus to various directions that the interest group can take. The more we can discuss these issues, the better our scholarship can be.

Further, the pre-conference event offered the space and structure for researchers to interact and discuss these topics in smaller groups and in-person. This first activity helped create these initial connections that planted the seed for new developments in the theory and empirical analysis of equity in health and healthcare.

What can economists do to improve health equity?

As a profession, we clearly need to do more. One way to do so is by diversifying the profession, because people’s backgrounds and lived experiences can inform which topics are studied and how they are approached. This includes research on health equity and health disparities. I think we need to find ways to help students and young scholars from underrepresented backgrounds feel that economics (and health economics) has something to offer them. This likely means starting earlier in the pipeline to introduce students and young adults to the field and to highlight the broad set of questions economists consider. But it doesn’t stop there. We need to continually ask ourselves how to make scholars feel included and supported once they are in a graduate program or a new academic or professional position. This likely requires continuously reflecting on what has and hasn’t worked towards this goal and committing to actions that could improve the sense of inclusion and belonging for all.

In terms of research, as a first step economists must open the space for creation and dissemination of health equity research. Second, academic economists can incorporate health equity topics into their classes, especially in health economic courses. Finally, if our research has some clear public policy implications or improvements to private regulations, we could take the lead in starting general discussions outside academic conferences and journal publications.

How can ASHEcon best support people working to improve health equity?

There are many things that ASHEcon can do. Two that come to mind are helping people with similar interests get together to share ideas and comments, and ensuring that health equity is a visible part of the profession’s interests. This can occur through regular presentations at annual meetings and plenary sessions.

The creation of a special theme for the ASHEcon annual conference was a very first step, together with the special workshop and pre-conference activities. ASHEcon has the capacity to create and design these spaces where interest groups can start conversations on common topics. It must continue and become a core section of the activities that the association organizes. On the more policy and general audience scenario, as an institution, ASHEcon could proactively explore its role in the development of official reports like the Healthy People 2030 or consider the development in these types of reports part of the discussion in the special groups’ regular activities.

References

Fleurbaey, Mark. (2006), “Health, Equity and Social Welfare,” Annales d’Économie et de Statistique, No. 83/84, Health, Insurance, Equity (Jul. – Dec.), pp. 21-59