Government Spending and the Two-Way Causation between Socioeconomic Status and Health in the UK: A Multilevel Structural Equations Modelling Approach

政策在勾勒健康模式和缓解健康不平等方面至关重要。有证据表明，基于不同意识形态的不同政策制度对个人和人口健康的影响是不同的。例如，与实施较少新自由主义政策的国家相比，坚持自由政策的国家会导致更严重的健康差距和更高的死亡率(Coburn 2004；Navarro等人)。2006年；Beckfield and Krieger，2009；Stuckler，King，and McKee，2009；McCartney等人。2012年；沃尔什等人。2017年)。在对健康不平等的唯物主义解释中，政策的财政部分是核心。自从英国政府委托的布莱克报告(Black 1980)发布以来，这样的解释受到了许多研究人员的青睐。特别是，这些文献侧重于卫生系统的筹资如何决定一系列人口健康结果(德拉斯蒂乔瓦和菲尔兹莫泽2020年；拉赫曼和阿拉姆2020年)，包括与最近的新冠肺炎大流行爆发(隆加2020)有关的结果。但是，相对于与卫生直接相关的投资，在调查不同部门的政府投资对健康的好处方面的文献相对较少。研究非卫生部门政策对卫生的影响的现有文献基本上仍然是理论和描述性的(例如，Smith和Kandlik Eltanani，2015)。然而，考虑到通过解决健康差距的根本原因来缓解健康差距的政策倡议的潜力，调查非卫生支出对健康的影响是至关重要的。社会经济地位不平等(林克和费兰，1995年；阿德勒和纽曼，2002年)。社会经济状况的指标被认为是社会秩序基本层面的标志，社会秩序决定了资源的分配，包括那些能够避免疾病风险的资源(Cutler、Llera-Muney和Vogl，2011)。另一方面，随着时间的推移，健康状况也可能通过社会流动过程影响社会保障体系(Hoffmann、Kröger和Geyer 2019)。因此，考虑到社会经济和健康之间的动态同步，重要的是评估政府政策如何通过以下两个方面形成健康不平等：(1)公共卫生支出和可能直接影响个人健康状况的政策，以及(2)与健康无关的领域的支出和政策，如教育、劳动力、收入和税收，这些领域改变了个人的社会经济状况，进而可能影响健康。本研究旨在解决以下问题。直接投资于人们的健康与改善他们在健康方面的社会经济地位的政策相比，有什么相对的影响？这些政策的影响是否会随着时间的推移而变化，如果是的话，它们是否取决于一个人的年龄、种族和其他社会人口特征？作为一个普遍假设，我预计公共卫生政策将在短期内对健康产生更大的影响，而非卫生政策将在长期内显现出来。我选择英国来回答上面的研究问题，是因为可以获得丰富的高质量的个人和人口水平的纵向数据。

Policies are critical in contouring patterns of health and mitigating health inequalities. Evidence shows that different policy regimes based on different ideologies have dissimilar impacts on individual and population health. For example, countries adhered to liberal policies are found to entail aggravated health disparities and greater mortality rates compared to countries that implemented less neoliberal policies (Coburn 2004; Navarro et al. 2006; Beckfield and Krieger 2009; Stuckler, King, and McKee 2009; McCartney et al. 2012; Walsh et al. 2017). The fiscal component of policies is central in the materialist explanations of health inequalities. Such explanations are favoured by many researchers since the release of the government-commissioned Black Report in the UK (Black 1980). Particularly, the literature focuses on how the financing of the health system determines an array of population health outcomes (Drastichová and Filzmoser 2020; Rahman and Alam 2020), including those related to the recent COVID-19 pandemic outbreak (Luonga 2020).However, the literature is relatively scarce in investigating the health benefits of government investments in different sectors than those directly related to health. The existing literature that looks into the implications of policies in non-health sectors on health remains largely theoretical and descriptive (e.g., Smith and Kandlik Eltanani 2015). Yet, investigating the health implications of non-health expenditure is crucial given the potential of policy initiatives in alleviating health disparities by tackling the fundamental causes of such disparities, viz. inequalities in socioeconomic status (SES) (Link and Phelan 1995; Adler and Newman 2002). Indicators of SES are thought to serve as markers of the underlying dimension of social ordering, which determines the distribution of resources including those that enable avoiding risks of illness (Cutler, Lleras-Muney, and Vogl 2011). On the other hand, health conditions may over time also affect SES through social mobility processes (Hoffmann, Kröger, and Geyer 2019). Therefore, taking into account this dynamic simultaneity between SES and health, it is important to assess how government policies shape health inequalities through both (1) public health expenditure and policies which may influence directly individuals' health status, and (2) spending and policies in non-health-related areas such as education, labour, income and taxation which alter individuals' socioeconomic circumstances and in turn may affect health.The proposed research aims to compare longitudinally the effects of public health and non-health policy domains on indicators of health and SES. The research aims to address the following questions. What are the relative effects of investing directly in people's health versus in policies that improve their socioeconomic position on health? Do these effects of policies change over time, and if so, do they depend on a person's age, ethnicity, and other socio-demographic characteristics? As a general hypothesis, I expect that public health policies will exert a greater short-run effect on health, whereas non-health policies will manifest themselves in the long run. I select the UK to answer the research questions above because of the availability of a wealth of high-quality individual and population level longitudinal data.