Abstract: During the COVID-19 pandemic we conducted two surveys of the population of The Netherlands. The first survey was carried out in April 2021, and the second in January 2022. We collected information on the general self-assessed health of the participants, both at the moment at which the survey was held and retrospectively, i.e. before the start of the pandemic. We also asked them about their willingness to get vaccinated (April 2021) and to get the booster shot (January 2022). In this paper we explore how self-assessed health and vaccination attitudes are related to income, age and gender. We use inequality indices, logit regressions and Oaxaca decompositions to analyse the data. Our results suggest that age and gender are crucial factors. We find evidence for a significant ‘age gradient’ in health, with older people tending to report better health than younger people. During the pandemic women’s health seems to have been affected more negatively than men’s health, with a lot of young women feeling depressed and anxious. This is reflected in higher levels of vaccine hesitancy among the young and among females.

Abstract: This paper explores the impact of the COVID-19 pandemic on patients’ experiences of general practice in England using multicategory response data from the 2020 and 2021 GP Patient Surveys, where the former was conducted in the run up to the first UK national lockdown at the end of March 2020 and the latter a year later. It offers a novel analysis of changes in patients’ experience that provides measures of practice quality change which are sensitive to changes in the distribution of patients across the full set of response categories not just in the proportion meeting some binary quality threshold. We find a 5.8 percentage point higher chance that a randomly chosen patient from anywhere in England would have reported a better rather than worse overall experience of their GP practice in 2021 than in 2020, whereas the proportion of patients describing their experience as ‘good’ only increased by 1.2 percentage points. Patients in 2021 were likely to rate their GP more highly if their last appointment was conducted face-to-face at their own practice rather than over the phone or online, suggesting that the improvement in patients’ rating of GP services was not the result of the prescribed move towards the greater use of remote consultations but of a change in reporting behaviour stemming from a more supportive attitude towards the NHS. Practice-level changes exhibit reversion towards the median quality for England as a whole, likely reflecting the influence of transitory shocks to patient experience at either patient or practice level.

Andrea Salas Ortiz, Abstract: Using a life-course perspective and based on Roemer's inequality of opportunity framework, the hypothesis of an accumulation and intergenerational transmission of ex-ante and ex-post inequality of opportunity in malnutrition is tested. This paper measures the evolution of inequalities in the light of the socioeconomic changes and the evolution of circumstances and efforts experienced by people born between 1983 and 1988 in Mexico. Using a combination of matching and re-weighting methods, a pseudo-birth-cohort is constructed and the effect of circumstances and efforts on the inequality of opportunity is disentangled and measured across nutrition-related health outcomes. Results indicate that inequality of opportunity in malnutrition has been a persistent issue across the life course of the birth cohort and that lack of opportunities have been transmitted from parents to children. When disentangling the contribution of circumstances and efforts to inequality in malnutrition, we find that, on average, people’s circumstances explain 72% of the explained variation, whereas efforts account for only 28%. We find that circumstances are the main driver of inequality in undernutrition, but there is insufficient evidence that efforts are the main driver of variation in overnutrition. The empirical results are relevant for reconsidering the classical assumptions behind the “economics of obesity”.

Jawa Issa, Abstract: Shifting mortality trends are causing life expectancy to stagnate or decline, leading us to reconsider how we assess improvements and deteriorations in age-at-death distributions. Attempts to rank age-at-death distributions by life expectancy and lifespan variation may fail if the two indicators conflict or produce a ranking that is not robust to the choice of inequality index and implied degree of inequality aversion. We propose non-parametric dominance analysis to obtain robust rankings that are founded on general ethical principles. We apply the approach to age-at-death distributions derived from United States period life tables for 2006-2018. Until 2014, more recent years often stochastically dominate earlier years at the first or second order. Preference for older and less unequal ages at death is sufficient to conclude from these results that the age-at-death distribution was improving in this period, particularly for non-Hispanic blacks and Hispanics. Since 2014, earlier years have often dominated more recent years at reasonably low orders, indicating a worsening of the age-at-death distribution according to ethical principles that many may find appealing. The deterioration is apparent for all sex and race groups.

Abstract: When the number of people one can save from harm is fixed, and the difference in harm one can save people from is substantial, standard principles for health resource allocation prioritize by severity. For example, if death is a substantially greater harm than paraplegia, then saving one from death takes priority over saving a different person from paraplegia. Standard principles are also fully aggregative: one death can be outweighed not merely by a large number of cases of paraplegia, but also by a sufficiently large number of very minor burdens (such as a case of toenail fungus). While prioritization by severity in fixed-number cases involving substantially different harms is uncontroversial among leading thinkers, many have challenged full aggregation. Instead, they have proposed a limited form of aggregation, on which a large number of cases of paraplegia can outweigh one death, but no number of cases of toenail fungus can outweigh one death. One reason cited in favour of limited aggregation is its supposed better fit with people’s considered moral judgments. There is, however, a lack of evidence on the public’s views. Here, we report the responses of a representative sample of the UK population to priority-setting dilemmas. We find that around half of respondents do not always adhere to prioritization by severity, primarily because of an apparent dislike for selecting one group facing death over another same-sized group in lesser, but still grave, need. However, among the remaining respondents, limited aggregation is much more popular than full aggregation. Our central results are robust to a test for status quo bias. They indicate that an overwhelming majority of people’s views do not align with standard priority setting principles, and that among those who prioritize by severity, limited aggregation is by far the most common view.

Abstract: Obesity is associated with lower educational attainment, lower income, and lower likelihood of being in skilled employment. Some of this association is likely to reflect the social causation of obesity. However, experience of weight-related stigma/discrimination, and the health consequences of high body weight could lead to obesity contributing to downward social mobility. Teasing apart the directionality of these effects is challenging with observational data. Mendelian randomization (MR) is an approach that uses genetic variants related to an exposure of interest (here, BMI) as instrumental variables. The approach exploits the natural experiment of genetic variants being randomly assigned at conception, which means they are less likely to be associated with factors that would confound a traditional analysis and should not suffer from reverse causality. In this seminar, we will present the findings of MR studies interrogating the causality of associations between BMI and socioeconomic outcomes.

Chris Lubker, Abstract: Deaths of despair (DoD) – deaths from drug overdoses, alcohol-related incidents, and suicides – are a growing epidemic, observed more often in groups with lower educational attainment. Previous studies assess socioeconomic inequalities in DoD for single countries or causes, but there have not yet been any international comparative studies of combined DoD. This study uses high-quality linked and supplementary unlinked mortality data to assess educational inequalities in DoD in 14 OECD countries in 2013-19, for a total coverage of 1.4 billion person-years. We calculate absolute and relative educational inequalities in DoD age-standardised mortality rates (ASMRs) using slope and relative indices of inequality. We also describe contributions of DoD to absolute gaps in life expectancy at 25 and rate differences in all-cause ASMRs. Among women (men), average SIIs in DoD ASMRs decrease from 29 (89) to 5 (77) deaths per 100 000 between age groups 25-64 to 65-89. DoD in women and men ages 25-64 contribute 7 and 11%, respectively, to the total life expectancy gap between high and low education groups, on average. DoD account for over 15% of rate differences in ASMRs among women and men ages 25-64 in USA, South Korea, and Sweden and men ages 25-64 in Australia and Canada.

Måns Abrahamson, Abstract: Preference laundering concerns regulating the set of preferences to be used as basis for judgements about individual or social interest. The central idea is that, depending on the purpose of any given analysis at hand (e.g., making welfare judgements), only some preferences are relevant—preferences that (approximately) satisfy specific conditions. Preference laundering can therefore be understood as a framework with three central steps: (i) specifying the conditions of relevant preferences; (ii) measuring to what extent actual preferences satisfy these conditions in domains of interest; and (iii) making use of different preference laundering practices to elicit preferences closer to the specified conditions. While the notion of ‘preference laundering’ is infrequently used in health economics, significant attention is paid to devising practices aimed at improving the quality of elicited preferences for health state valuation and healthcare priority-setting. In this article, I review practices of (implicit) preference laundering in health technology assessment and situate these practices in a broader perspective of seeking to elicit ‘laundered’ preferences. In doing this, I highlight a number of shortcomings of current preference elicitation procedures that, I argue, can more successfully be addressed by explicitly invoking an integrated framework of preference laundering.

Abstract: We propose two measures of population health that, like health adjusted life expectancy (HALE), can be calculated from a health-extended period life table. Unlike HALE, both measures are sensitive to inequality in health adjusted lifespans and in health at each age. The first measure – equivalent health adjusted lifespan (EHAL) – is a generalisation of HALE (and life expectancy). The second measure is the willingness to pay of a risk averse representative agent behind the veil of ignorance for change in lifespan and age-specific health distributions. We use these measures and data from the Global Burden of Disease to evaluate trends in population health in Sub-Saharan Africa (SSA) between 1990 and 2017, and to consider prioritization of diseases. Allowing for aversion to inequality in health at each age has relatively little impact on HALE. But incorporating sensitivity to inequality in health distribution adjusted lifespan has a large impact. While HALE increased by around 20% over the period, EHAL increased by 30%. Allowing for distributional sensitivity substantially increases the value attached to the elimination of communicable diseases (CDs), while it reduces the welfare gain from the elimination of noncommunicable diseases (NCDs). The convergence in the burdens of CDs and NCDs in SSA that has previously been observed is greatly reduced using distributionally sensitive valuation of their respective impacts on population health.

Abstract: Effective policy requires the science of both facts (how the world is) and values (how it ought to be). We have learned a lot over the past year about the facts related to SARS-CoV-2 but we still know remarkably little about how the general public values reducing mortality risks across different age groups, and against other possible outcomes, such as mental health problems and job losses. Methods: We conducted an online discrete choice experiment (DCE) to elicit the preferences of the UK public using two samples on two occasions: May 2020 (n= 6,153) and February 2021 (n=1,024). The DCE had four attributes: excess deaths above age 70; excess deaths below age 35; extra number of mental health problems in those aged 16-34; and extra job losses in those aged 16-34. Results: The relative value of mortality above 70 to below 35 is roughly 1:24, and one elderly death is equivalent to four mental health problems or just under three jobs lost in younger people. Alongside scale heterogeneity, there is also evidence of preference heterogeneity across the two surveys and across respondents of different ages. Conclusion: Studies of this kind provide means by which effective policy decisions can fully “follow the science”, by delivering the evidence on values. Our results suggest a potential disconnect between public preferences and current Covid-19 policies.

Abstract: Studies of people’s aversion to health inequalities indicate that most people are willing to trade off some gains in health improvements to achieve reductions in unfair health inequalities. Most studies also indicate that aversion to health inequalities is stronger than for income inequalities. This presentation will provide three examples where aversion to health inequalities could affect priority setting: differentiated cost-effectiveness thresholds according to pure health inequality; investing in cycle networks in areas of relative deprivation; and comparing two funding options for cancer treatment in a low-income country. We use a practical prioritarian approach to economic evaluation of health interventions, taking into account impacts on health, income and health, and lifetime wellbeing. Although standard cost-effectiveness analysis is not very sensitive to concerns about redistribution, a prioritarian approach to economic evaluation can incorporate such concerns. The presentation ends with a discussion of whether people’s aversion to health inequality should influence priority setting, and if so, how these methods could be further improved.

Abstract. As the severity and frequency of natural disasters become more pronounced with climate change and the increased habitation of at-risk areas, it is important to understand people’s resilience to them. We quantify resilience by estimating how natural disasters in the US impacted individual wellbeing in a sample of 2.2 million observations, and whether the effect sizes differed by individual- and county-level factors. The event-study design contrasts changes in wellbeing in counties affected by disasters with that of residents in unaffected counties of the same state. We find that people’s hedonic wellbeing is reduced by approximately 6% of a standard deviation in the first two weeks following the event, with the effect diminishing rapidly thereafter. The negative effects are driven by White, older, and economically advantaged sub-populations, who exhibit less resilience. We find no evidence that existing indices of community resilience moderate impacts. Our conclusion is that people in the US are, at present, highly resilient to natural disasters.

Abstract. A welfare criterion that is sensitive to preference heterogeneity is necessary if we want to take ethnic differences into account when evaluating a policy program. We propose the natural criterion that a program benefits a recipient if she is lifted to a higher indifference curve. We discuss the difference between this criterion and an alternative one that uses a self-reported subjective well-being measure to evaluate a policy program. The use of both criteria is illustrated by studying the effects of the introduction of a non-contributory pension program (Pension 65) in Peru. This program is found to have a different effect on the outcomes of the three main ethnic groups, i.e., Mestizo, Quechua, and Aymara. The Aymara beneficiaries of the program have experienced larger increases in health compared to other Peruvians. Using a panel life satisfaction regression, we find evidence for preference heterogeneity between the Aymara and the other ethnic groups that is consistent with the observed differences.