Dec 31, 1997
Decades of demographic research about older Americans indicate a strong association between level of wealth and status of health. This association has led some to conclude that senior citizens who have more household wealth are healthier simply because they can afford better health care as they age. The implication of this view is that programs providing poorer elderly citizens with more funds for health care would minimize the existing disparity in health status and enable these poorer individuals to function as effectively as their wealthier counterparts.
More-recent research, however, has suggested that this diagnosis and its accompanying prescription are based on an oversimplified picture of the interrelationship between health and wealth. As the nation prepares to redesign its Medicare, Medicaid, and Social Security policies, therefore, it still does not have a clear grasp of how health and socioeconomic status (SES) interact and affect the lives of the elderly.
James P. Smith and Raynard Kington, researchers at the RAND Center for the Study of Aging, have recently attempted to provide additional insights into this interaction by examining disparities in functional health status among older Americans. Using an important new survey, the Asset and Health Dynamics Among the Oldest Old, the researchers offer extensive support for the view that the association between health and wealth flows in both directions—quality of health influences economic status as well as the other way around.
The study proceeds by addressing three basic questions concerning the relationship between level of economic resources and health status in old age. The first concerns the most appropriate way to measure a household's total resources, an indispensable step in understanding the reasons behind the SES-health relationship. The second focuses on the extent to which a household's economic resources are influenced by both current and long-term health status. The third concerns the strength of the connection between health status and SES across racial, ethnic, and gender lines.
The study's results suggest that the conventional method of measuring the economic resources of the elderly—looking only at current household income aggregates—is far from adequate. Such an approach does not provide a proper basis for understanding the health effects of additional economic resources because the incomes of older individuals are affected by both current and long-term feedbacks from health to income. Dividing total household income into five distinct subcomponents (earnings, social security, pensions, welfare, and other) and distinguishing between income received by the survey respondent and income received by the spouse proved to be a much more reliable basis for understanding how health and economic resources interrelate.
The research indicates that the strong SES-health nexus for the elderly is essentially a consequence of persistent health outcomes over long periods. The ability of individuals to reach and secure an independent income for their advanced years can be greatly affected by the condition of their health over their lifetime. Long-term health status may have an impact on schooling, marriage, childbearing, and, eventually, on lifetime earnings and household wealth.
Health in old age similarly reflects one's long-term health history. The study's findings show that health status in advanced years is greatly influenced by a history of health that goes back to one's childhood and reaches even beyond personal health status to include the health status of parents and siblings throughout their lives. Thus, elderly individuals whose parents and siblings survive into old age are less prone to disease and less likely to experience limitations in basic functions such as ability to work, climb stairs, and lift objects. Whether this correlation reflects shared genetic endowments—where some families are healthier than others—or the cumulative impact of common social, economic, and geographic environments remains an important unanswered research question.
This long-term SES-health interaction is especially significant for elderly Americans who belong to minority groups. The research supports earlier work showing that Hispanic and black senior citizens bear a greater-than-average risk of losing their functional abilities. However, it appears that they do so not because they are less affluent but because their poorer health histories make them more vulnerable to functional limitations and simultaneously reduce their ability to accumulate wealth. In other words, the greater inability of these minority groups to function effectively in old age has little to do with race or ethnicity per se. It is only a slight oversimplification to conclude that the SES-health relationship (whatever its causal pathway) explains all racial and ethnic disparities in the capacity to function among the elderly.
Although the interaction of SES and health accounts for variations in old-age functioning across racial and ethnic lines, it cannot explain why elderly women do not function as well as men. This gender gap may be the result of hormonal differences related to reproduction, indicating that the cumulative effect of maternal depletion persists into old age. Other possible explanations involve differences in how men and women perceive and report symptoms and health outcomes. Women's more frequent contact with the health care system may lead to greater awareness and greater likelihood of reporting health problems. Additionally, differential mortality by sex may play a role—because men in poor health die younger, only the more robust men are counted among the elderly.
Both wealth and health at old age are greatly influenced by long-term health history—by a long line of events in the health status of individuals and their families. Yet this important relation between SES and health offers only a partial explanation for differences in the health of various groups of elderly Americans. Besides giving little insight into the poorer health status of older women, it provides results that are highly nonlinear across different economic strata. While the SES-health correlation is strong at the lowest socioeconomic levels, it becomes weaker at mid levels, and is almost nonexistent at the upper levels. These results suggest that the reasons for different health outcomes among senior citizens are more complex than has been previously believed. As vast numbers of Americans from the "baby boom" generation reach advanced age, it becomes increasingly important to identify the full range of factors that bear on their health status. Without a comprehensive explanation of differences in health outcomes at old age, policymakers will find it difficult to make effective adjustments to programs that have a profound impact on the well-being of senior citizens.