Live and let die? Laissez-faire responses to the pandemic exacerbated unequal health usage
15th June 2021
Author: William Foley, European University Institute.
Income and healthcare usage – an association in some countries
Income inequality has increased over the course of the pandemic (Darvas, 2021). To make matters worse, it is the poorest who have suffered the most, from the disease itself, as well as from the economic and social chaos that has come in its wake (Stiglitz, 2020). Using data from the Six-Country Survey on Covid-19 (Belot et al., 2020), I and my co-author, Klarita Gërxhani, show that in some countries only, poorer people are less likely to go to the doctor when experiencing potential Covid-19 symptoms. This income gradient was evident in three of six countries studied: the US, Britain, and (to a lesser extent), Japan. But in three other countries – China, South Korea, and Italy – there was no such relationship.
Using International Social Survey Programme data from 2012/13, we show that this cross-national pattern is unique to the pandemic. It is not the case in the US, Britain, or Japan, that lower-income people were more mistrusting of the health system in the pre-pandemic period, or were more likely to report financial and other obstacles to healthcare access.
This finding presents a puzzle. It is not surprising that an income gradient might exist in the US, where healthcare is expensive and underprovided to poorer people. However, Britain’s National Health Service is free at the point of access. Direct financial costs cannot explain this pattern.
Government intervention closes the income gap in healthcare usage
In our article, we show that the strength of the income gradient appears to correlate with the intensity of government response to the pandemic. In the US, Britain, and Japan, those in the top income quintile are about 20 percentage points more likely to attend the doctor than those in the bottom quintile. There is no such gap for China, Italy, and South Korea. The US, Britain, and Japan are also the countries which score the lowest on the Oxford COVID-19 Government Response Tracker’s “stringency index” (Hale et al., 2020), a measure of how intensely the government responded to the pandemic. In the countries where governments took a firmer hand in response to the pandemic, there was no income difference in healthcare usage.
We argue that this effect is driven by the differential sense of agency possessed by those at the top and bottom of the class hierarchy. Working class people have fewer financial and cultural resources, and less control and authority in the workplace. They experience less control over their lives, when compared to middle class people (Kraus et al., 2012; Lachman and Weaver, 1998; Snibbe and Markus, 2005). Low-agency individuals are less likely to seek medical attention and follow medical guidelines (Rutger 2007), perhaps because they have a more fatalistic attitude towards life (Tapal et al., 2017).
Government support can play some role in boosting the agency of working class people. Where agency is diminished by a lack of resources, welfare payments can provide a degree of economic security, especially during the pandemic. Governments can also pass statues to prevent termination of employment, or effective pay cuts, when workers take sick leave. Empirically, support for low-wage workers has mitigated the inequality-enhancing effect of the pandemic (Aspachs et al., 2021).
Support – not coercion
I do not think our findings should be interpreted as support for draconian state measures. Agency is not boosted by taking away a sense of control from people’s lives – quite the opposite. Governments should support and assist people, foregoing coercion.
In practice, governments which implemented heavy-handed policies tended not to provide positive support to the people. In India, the Modi government’s main response to the pandemic was a drastic lockdown, which was particularly devastating for the health and livelihood of the country’s 40 million internal migrants, many of whom found themselves stranded far from home, without food, water, or basic housing (World Bank, 2020). Those that did travel back likely contributed to the spread of the virus which has made India one of the countries most devastated by the virus.
Covid-19 has accelerated the widening of the income and wealth gap. But the pandemic’s unequal impact has not gone unnoticed it seems. At least in Britain, people seem to have become more inequality averse during the pandemic (Asaria et al 2021). It will be interesting to see what, if any, political manifestation this change in attitudes will take.
Read the article Hands-off? Laissez-faire policies on Covid-19 may exacerbate health inequalities by William Foley, European University Institute; Klarita Gërxhani, European University Institute.
Asaria, M., Costa-Font J. and Cowell F. (2021), “How does exposure to COVID-19 influence health and income inequality aversion?”, IZA Working Paper, 14103. Available at: https://www.iza.org/publications/dp/14103/how-does-exposure-to-covid-19-influence-health-and-income-inequality-aversion
Aspachs, O., Durante, R., Graziano, A., Mestres, J., Reynal-Querol, M. and Montalvo, JG. (2021). Tracking the impact of COVID-19 on economic inequality at high frequency. PLoS ONE. 16(3): e0249121.
Belot, M., Choi, S., Jamison, J.C., Papageorge, N.W., Tripodi, E. and van den Broek-Altenburg, E. (2020). Six-Country Survey on Covid-19. Available at: https://osf.io/aubkc/
Darvas, Z. (2021). The unequal inequality impact of the COVID-19 pandemic. Bruegel. Working Paper 06/2021. Available at: https://www.bruegel.org/wp-content/uploads/2021/03/WP-2021-06_30032021.pdf
Hale, T., Webster, S., Petherick, A., Phillips, T. and Kira, B. (2020). Oxford COVID-19 Government Response Tracker, Blavatnik School of Government. Available at: https://www.bsg.ox.ac.uk/research/research-projects/covid-19-government-response-tracker
Kraus, M.W., Piff, P.K., Mendoza-Denton, R., Rheinschmidt, M.L. and Keltner, D. (2012), “Social class, solipsism, and contextualism: how the rich are different from the poor”, Psychological Review, Vol. 119 No. 3, pp. 546-572
Lachman, M.E. and Weaver, S.L. (1998), “The sense of control as a moderator of social class differences in health and well-being”, Journal of Personality and Social Psychology, Vol. 74 No. 3, pp. 763-773
Snibbe, A.C. and Markus, H.R. (2005), “You can’t always get what you want: educational attainment, agency, and choice”, Journal of Personality and Social Psychology, Vol. 88 No. 4, pp. 703-720
Stiglitz, J. (2020). Conquering the Great Divide. Finance and Development. International Monetary Fund. Fall 2020. Available at: https://www.imf.org/external/pubs/ft/fandd/2020/09/COVID19-and-global-inequality-joseph-stiglitz.htm
Tapal, A., Oren, E., Dar, R. and Eitam, B. (2017), “The sense of agency Scale: a measure of consciously perceived control over one’s mind, body, and the immediate environment”, Frontiers in Psychology, Vol. 8, pp. 1-11
World Bank. (2020). COVID-19 Crisis Through a Migration Lens. Migration and Development Brief 32. Available at https://documents1.worldbank.org/curated/en/989721587512418006/pdf/COVID-19-Crisis-Through-a-Migration-Lens.pdf