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

政策在塑造健康模式和减轻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不同。例如，与实施较少新自由主义政策的国家相比，坚持自由主义政策的国家被发现会导致更严重的健康差距和更高的死亡率（Coburn 2004； Navarro等人2006；Beckfield和Krieger 2009； Stuckler， King和McKee 2009； McCartney等人2012；Walsh等人2017）。在对健康不平等的唯物主义解释中，政策的财政成分是核心。自英国政府委托的黑色报告（Black 1980）发布以来，这种解释受到了许多研究人员的青睐。特别是，文献重点关注卫生系统的融资如何决定一系列人口健康结果（drastichov<e:1>和Filzmoser 2020； Rahman和Alam 2020），包括与最近的COVID-19大流行爆发有关的结果（Luonga 2020）。然而，在调查与健康直接相关的不同部门的政府投资对健康的好处方面，文献相对较少。研究非卫生部门政策对健康影响的现有文献主要是理论性和描述性的（例如，Smith和Kandlik Eltanani 2015）。然而，调查非保健支出对健康的影响是至关重要的，因为政策举措有可能通过解决这种差距的根本原因，即社会经济地位的不平等，来减轻健康差距（Link和Phelan 1995； Adler和Newman 2002）。社会经济地位的指标被认为是社会秩序底层维度的标志，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的分配（Cutler, Lleras-Muney, and 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经济地位（Hoffmann, Kröger, and Geyer 2019）。因此，考虑到社会经济地位和健康之间的这种动态同时性，必须评估政府政策如何通过以下两方面塑造健康不平等：(1)可能直接影响个人健康状况的公共卫生支出和政策，以及(2)教育、劳动、收入和税收等非健康领域的支出和政策，改变个人的社会经济状况，进而可能影响健康。拟议的研究旨在纵向比较公共卫生和非卫生政策领域对健康和社会经济地位指标的影响。本研究旨在解决以下问题。直接投资于人们的健康与投资于改善他们在健康方面的社会经济地位的政策的相对效果是什么？这些政策的影响是否会随着时间的推移而改变，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？作为一个一般假设，我预计公共卫生政策将对健康产生更大的短期影响，而非卫生政策将在长期表现出来。我选择英国来回答上面的研究问题，因为有大量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.