In the literature on inequalities, none of them is as important as the one reflected in differences in health. That one socioeconomic group has a lower life expectancy than another, or in years of life free of disabilities, hits the moral sense of a society. How we identify this group is not innocuous, either by income groups, by education level, by the place where you live, the job you have or the greater or lesser access to health systems. And we talk regarding inequalities, not inequities, which is a more imprecise concept than arithmetic – if something is equal to something, or not, it is always clearer than if it seems fair and equitable (‘fair’, as the English say).
In reality, it is difficult not to associate each of the above factors, individually or together, with unwanted social effects: poverty, deprivation, avoidable premature mortality. But following a long time watching how these inequalities remain constant or increasing, Even in public welfare systems, it is inevitable to think regarding the effectiveness of interventions. Someone can say, of course, that it is because the amount with which a policy is financed is not enough. Ask for a resource bazooka and not a precision shot. And he argues that it would be much worse to eliminate them. But the truth is that in the most active countries, which have spent millions and millions in combating inequalities, what has been observed in the best of cases is that the impact on the reduction of the mean value (or in improving health) has been positive. But to the extent that it has affected one social group more than another (the most ‘responsive’ to the extent being the most socially privileged), the difference – inequality – has not been reduced. Either it has not been reduced enough as expected, or it has not done so with the power that required a minimal evaluation of the dedicated resources. Such is the capacity of the economic system to create increasing inequalities.
There is a technical discussion today. Identify the most decisive factors in the maintenance and reiteration of health inequalities to particularly affect the most vulnerable groups, so that universal policies would be wrong, if we talk regarding reducing inequality in a serious way. Universal access is in effect no guarantee of reduction, and less on a recurring basis, due to the different habits of use that our states of well-being provoke today, and if they would be highly objective measures at destination.
I do not discover the wheel here, but I would like to emphasize that in a context of scarce resources we must focus more and put aside (unfortunately, since we cannot dedicate more resources, no matter how positive the effects they cause) those that they do not pass a minimal evaluation of cost and results. And so we can prioritize the policies that we know are direct and successful: in the field of health, the fight once morest tobacco, alcohol abuse, sedentary lifestyle and obesity. Not universal basic income -If it is basic and universal, it is infinite-, no more and more unequal value healthcare packages, not generic denials of public rates and prices, as is done today by the draft bill of universal equity and cohesion of the Spanish government.
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In any case, someone can go on arguing that If everyone had a better education, equal income, good jobs and a childhood of excellence, everything would be better. Because it is unrealistic, we must focus on those things that, being within reach, can work better due to the effectiveness they show in reducing the health differential per euro spent. And make no mistake: what is said regarding the great redistributive effect of spending, generically, on pensions, education or health to combat inequalities is due to the amount of what is spent (the bazooka), not per euro spent : housing is here the most redistributive social policy. Because per euro spent, it is addressed today to those who need it most selectively.
Following the previous recommendation, some health economists think that directing public action to reduce ‘averages’ to focus on the ‘tails’ of the distribution of inequality will lose the legitimacy of the social protection system. It may be, but the cost of not doing so, in the midst of questioning the financial sustainability of the welfare state, is maintaining a level of social inequalities that are unacceptable for many.
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