Public Health Observatory, National Health Service (NHS) Health Scotland, Edinburgh, UK.
Public Health Observatory, NHS Health Scotland, Glasgow, UK.
Lancet Public Health. 2020 Mar;5(3):e150-e156. doi: 10.1016/S2468-2667(20)30011-6.
The unequal distribution of income is a fundamental determinant of health inequalities. Decision making around economic policies could be enhanced by showing their potential health effects. We used scenario modelling to assess the effects of 12 income-based policies on years of life lost (YLL) and inequalities in YLL in Scotland for the 2017-21 period.
In this modelling study, we used EUROMOD version H1.0+, a tax-benefit microsimulation model, to estimate the effects of hypothetical fiscal policies on household income for Scottish households in the 2014/15 Family Resources Survey (n=2871). The effects were modelled excluding housing costs. Income change from baseline was estimated for each quintile of the 2016 Scottish Index of Multiple Deprivation (SIMD) after weighting to account for differential non-response to the Family Resources Survey, and incomes were equivalised according to the Organisation for Economic Co-operation and Development's modified equivalence scale. A regression analysis of cross-sectional data was used to estimate the relationship between income change and all-cause mortality, followed up by a sensitivity analysis to account for uncertainties around the assumptions on effect size. Informing Interventions to reduce health Inequalities (Triple I), a health inequalities scenario modelling tool, was used to estimate policy effects on YLL and government spending after five years of theoretical implementation. The Triple I model used population estimates for 2016 stratified by sex, 5-year age group, and SIMD quintile, which were obtained from the National Records of Scotland. Preliminary estimates of relative policy costs were calculated from the EUROMOD-derived combined effects of each policy on tax bills, National Insurance contributions, and benefits receipts for Scottish households.
Taxation-based policies did not substantially affect household incomes, whereas benefits-based policies had large effects across the quintiles. The best policy for improving health and narrowing health inequalities was a 50% increase to means-tested benefits (approximately 105 177 [4·7%] YLL fewer than the baseline of 2·2 million, and a 7·9% reduction in relative index of inequality). Effects on YLL and health inequalities were inversely correlated in response to changes in taxation policy. Citizen's Basic Income (CBI) schemes also substantially narrowed inequalities (3·7% relative index of inequality for basic scheme, 5·9% for CBI with additional payments for individuals with disability), and modestly reduced YLL (0·7% for the basic scheme and 1·4% with additional payments). The estimated government spending associated with a policy was proportional to its effect on YLL, but less closely related to its effect on inequalities in YLL.
Policies that affect incomes could potentially have marked effects on health and health inequalities in Scotland. Our projections suggest that the most effective policies for reducing health inequalities appeared to be those that disproportionately increased incomes in the most deprived areas. Although modelling was subject to various assumptions, the approach can be useful to inform decisions around addressing the upstream determinants of health inequalities.
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收入分配不均是健康不平等的根本决定因素。通过展示经济政策的潜在健康影响，可以增强决策的合理性。我们使用情景建模来评估 12 项基于收入的政策对苏格兰 2017-21 年期间生命损失年数 (YLL) 和 YLL 不平等的影响。
在这项建模研究中，我们使用了欧盟模式 H1.0+，这是一种税收-福利微观模拟模型，以估计苏格兰家庭资源调查（n=2871）中假设财政政策对家庭收入的影响。在不考虑住房成本的情况下，对每个苏格兰多因素贫困指数（SIMD）2016 年五分位数的收入变化进行建模。在对家庭资源调查的差异无反应进行加权后，估计了基线收入的变化，并根据经济合作与发展组织的修正等价规模对收入进行了均等化。使用横截面数据的回归分析来估计收入变化与全因死亡率之间的关系，然后进行敏感性分析以考虑对效应大小的假设的不确定性。用于减少健康不平等的干预措施（Triple I），是一种健康不平等情景建模工具，用于估计五年理论实施后政策对 YLL 和政府支出的影响。Triple I 模型使用了 2016 年按性别、5 岁年龄组和 SIMD 五分位数分层的人口估计数，这些数据是从苏格兰国家记录中获得的。初步估计的相对政策成本是根据欧盟模式得出的每个政策对苏格兰家庭的税收、国民保险缴款和福利收入的综合影响计算得出的。
基于税收的政策对家庭收入没有产生重大影响，而基于福利的政策对所有五分位数都有较大影响。改善健康状况和缩小健康不平等差距的最佳政策是将福利金提高 50%（与基线 220 万相比，YLL 减少约 105177[4.7%]，相对不平等指数降低 7.9%）。税收政策变化与 YLL 和健康不平等之间的关系呈反比。公民基本收入（CBI）计划也大大缩小了不平等差距（基本计划的相对不平等指数为 3.7%，CBI 为 5.9%，对残疾个人的额外支付），并适度降低了 YLL（基本计划为 0.7%，有额外支付的为 1.4%）。与政策相关的政府支出与 YLL 的影响成正比，但与 YLL 不平等的影响不太相关。
影响收入的政策可能会对苏格兰的健康和健康不平等产生显著影响。我们的预测表明，减少健康不平等最有效的政策似乎是那些不成比例地增加最贫困地区收入的政策。尽管建模受到各种假设的限制，但该方法可以用于为解决健康不平等的上游决定因素提供信息。
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