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    Arrow Steve

    While I support efforts to reduce health inequalities, the report (linked) prompting discussion this week is not of a high quality. A couple of preliminary issues come to mind:

    1) It is purporting to count the benefits for a treatment that doesn’t exist, and I feel, disrespecting the social determinants of health. Income and education are extremely predictive of health status and life expectancy all across the world (and across time). This report asks, ‘what if this disparity did not exist’? How exactly is this equalization supposed to be achieved?

    2) Like many economic evaluations built for advocacy purposes, it counts the (very hypothetical) benefits of equality, but not the costs. Reduced health expenditures on a per year basis need to be evaluated on a life-course perspective, as presumably we are also reducing inequities in life expectancy. Likewise, seniors transfer payments ought to be included.

    Claims that a magical reduction in health inequity are likely to result in a “benefit cost ratio (that) must be massive” as Dr. Mooney does are entirely unfounded, and more reflective of a political argument than one based on evidence. If we can’t identify the changes to society that are required to lead to these benefits, how can they possibly be costed?

    There are moral and political arguments for equality. There are arguments based on evidence. Advocates of progressive policy do themselves a disfavor when they attempt to stretch evidence to get the public’s attention.

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    Gavin Mooney

    Steve Arrow claims to support efforts to reduce health inequalities but is then critical of the NATSEM report as being ‘not of high quality’. How one judges quality can be tricky but here I think quality must be in terms of the technical skill involved in the analysis and I certainly would not question that, especially when the report is out of the NATSEM stable.

    It may not be possible to achieve equalisation but we can go a long way through reducing poverty and inequality and providing more equal opportunity for education and housing. There are examples of societies which have gone down this road and achieved remarkably good health for their income levels. So the ‘treatment’ is not perfect but it does exist, albeit imperfectly.

    I did not present the costs but as an economist I anticipated that readers would assume that I would know that there would be costs. (“Seniors transfer payments” by the way are not costs; they are transfer payments.)

    What is interesting to me is that much of what is needed to promote the SDH is a reduction in inequality. If income were to be redistributed from rich to poor, given the concept of the ‘diminishing marginal utility of income’ (the idea that an extra dollar is valued less the more we already have), then the value of the benefit of such redistribution is positive.

    Given these points I disagree that my claims ‘that a magical reduction in health inequity are likely to result in a “benefit cost ratio (that) must be massive”’ are ‘entirely unfounded’.

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