Economic Policy: An Important (But Overlooked) Piece of "Health in All Policies"

Increasingly, efforts to improve Americans’ health recognize the need to reach beyond the traditional health care and public health sectors to address the “non-medical determinants of health” (McGinnis et al., 2002). We see this in calls for policy change in the domains of housing, transportation, security, education, and other areas shaping the contexts in which people live, learn, work, and play (IOM, 2011; Kickbusch, 2010; Woolf, 2009). Recently, these efforts have come together under the notion of Health in All Policies (HiAP)—in which health is advanced as a salient outcome of interest for policy makers both inside and outside traditional health domains.

One set of “non-health” policies likely to impact health are the economic policies shaping the distribution of income and wealth in our society—including laws aimed at capturing more or less of the income among the wealthy (e.g., marginal tax rates, corporate taxes), providing income support to lower-income citizens (e.g., Earned Income Tax Credit [EITC], welfare), and regulating the marketplace (e.g., minimum wage, monetary policy). However, these economic policies are rarely central to HiAP efforts, which are more likely to focus on cross-sector collaboration and planning at the local or community levels than at the federal or state levels in which many economic policies are set.

Similarly, the Pew Health Impact Project’s database illustrates that the majority of health impact assessments focus on the built environment (32 percent) or transportation (22 percent), followed by natural resources (14 percent), agriculture/food policy (8 percent), and housing (8 percent). (The Pew Health Impact Project database is available at http://www.healthimpactproject.org/hia/us.) Less often do these studies examine economic policies—with a few important exceptions, such as Bhatia and Katz’s (2001) estimates of positive health effects from a proposed living wage ordinance in San Francisco and the Pew (2013) assessment of proposed changes to the federal food stamp program. Likewise, the National Prevention Strategy (The National Prevention Strategy is available at http://www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf.) developed by the interagency Prevention Council calls attention to the importance of income and wealth as determinants of health, but makes little mention of taxes, monetary policy, market regulation, or spending on social services other than housing in its policy recommendations (Rigby, 2011).

This tendency for HiAP efforts to overlook economic policies that (re)distribute income is surprising in light of the strong evidence that one’s socioeconomic status is closely tied to one’s health outcomes. We know that wealthier individuals have better health outcomes—often measurable in terms of years, or even a decade, of longer life (Haan et al., 1989; Lantz et al., 1998; Marmot et al., 1991; McDonough et al., 1997; Menchik, 1993; Pappas et al., 1993). And this socioeconomic gradient in health is found across different geographic units, and almost all causes and indicators of morbidity, limitations and disability, and mortality (Schoeni et al., 2010). In addition, research on income inequality has found greater health inequality where income is distributed most unevenly (Kawachi and Kennedy, 1993; Kondo et al., 2009; Lynch et al.,1998; NRC, 2013; Wilkinson and Pickett, 2009).

Yet, evidence of persistent socioeconomic disparities in health does not translate directly into causal evidence that any economic policy change would impact health (Kawachi et al., 2009). In fact, we have few studies on the health impacts of economic policies. Even in Schoeni and colleagues’ (2010) book Making Americans Healthier: Social and Economic Policy as Health Policy—a high-profile edited volume specifically commissioned to address the lack of research on the health effects of non-health policies—only a few chapters examined economic policies, with the most direct investigation undertaken by Herd and colleagues (2010), who found positive health effects of Social Security payments among the elderly. Another notable exception is an evaluation by Hoynes and colleagues (2012), who examined the health impact of the EITC (a tax refund targeted at low-income working families). They found that an increase in the credit “reduced the incidence of low birth weight and increased mean birth weight” (Hoynes et al., 2012)—concluding that economic policy that serves to increase income can improve health. Clearly, much more of this research is needed, for use by health policy makers who need compelling evidence to advocate for policies that benefit health, as well as by economic policy makers who may currently be unaware of the health consequences of their policy choices.

We also need to pay greater attention to documenting the co-benefits and interdependencies among health and other outcomes prioritized by those making economic policy decisions. This is essential since in many ways HiAP is quite ambitious—aiming to change the culture and discourse around non-health policies in order to place “health criteria on the agendas of a broad range of policymakers who have not previously considered health as part of the agenda” (Sihto et al., 2006, p. 11). This aim quickly confronts a paradox of governance in which the “non-health policy makers” on which HiAP efforts depend hold conflicting priorities and face few incentives to incorporate health considerations into their work (Bardadch, 1998; Rigby, 2011). To overcome this paradox, it can be helpful to identify what Ollila (2011) calls “win-win strategies” in which both health and the outcomes of interest to those outside the health sector can be advanced by the same policy design. Unfortunately, it may be particularly difficult to sell economic policy makers on these win-win strategies since theirs is a policy area already high on the public agenda and in little need of developing a health-based rationale to justify ongoing governmental attention to economic policy and outcomes. As a result, maintaining the long-term involvement of economic policy makers in HiAP initiatives will often prove challenging.

Further, economic policy making in the United States may be less hospitable to the development of HiAP initiatives due to the polarized, partisan, and ideological politics surrounding these issues. In fact, it is hard to find an economic policy proposal without organized opposition bringing heated political rhetoric of class warfare, unfair government redistribution, or similar charges. For these reasons, HiAP efforts may shy away from engaging in polarizing economic policy debates in an effort to build stable cross-sector collaborations and avoid identification with one ideological position or another. Yet, this safe strategy may not be worth the trade-off since, by overlooking a whole set of policies shaping the distribution of income and wealth in our country, we may risk missing many of the most promising policy levers available for reducing socioeconomic disparities in Americans’ health.

 

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