Interview: “Dramatic improvements in health”

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Professor Joachim Winter and Peter Redler from the Chair of Empirical Economic Research at LMU have published a study on trajectories of life expectancy and income in Germany with a focus on East–West differences. A second paper compares these data with the situation in the US and Europe as a whole.

You analyzed the development of life expectancy and income in Germany over the past 30 years. Can you give a quick summary of the results?

Peter Redler: We ranked all of the administrative districts in terms of mean disposable income, and asked how this parameter correlated with mortality rates. Our main result is that, taking Germany as a whole, mortality is higher in regions in which the average income is lower. However, over the period 1990-2015, the degree of regional inequality has fallen. When the country was re-united, the difference in mortality rates between East and West Germany was relatively large, but that gap has since narrowed.

Joachim Winter: We found that dramatic improvements have taken place in the healthcare since reunification – also in East Germany, and particularly with respect to life expectancy. One can of course pose the question of where deficits remain. But overall, the health system in Germany, as in most other developed countries, is very efficient. This has been confirmed during the pandemic.

You have shown that the link between economic inequality and mortality is no longer as strong as it used to be. What are the reasons for this?

Joachim Winter: Several factors account for this development. The most important one is that the quality of general medical care has improved, especially in less well-off districts. In addition, all parts of the population now have better access to healthcare.

Peter Redler: We also looked at the quality of the health system in the East prior to reunification. Up until the 1970s, it was relatively modern, and comparable to the standards in the West. In the 1980s, it declined and was not sufficiently well financed. Following reunification, it caught up relatively quickly as it adopted the health system of the West.

Joachim Winter: In the East, many industries were significantly less efficient than their counterparts in the West. After reunification this led to their demise, with a corresponding loss of jobs. But a lot of money was invested in the public sector, and this enabled the East to close the gap in many dimensions including health care.

Developments in the US compared with the situation in Europe

In a second paper, you report that children and adolescents are very well cared for in Europe, also in comparison with the US.

Peter Redler: In particular the infant mortality rate – death during the first year of life – in the US is higher than it is in comparably wealthy European countries. When one compares it with mortality rates of children and adolescents aged 1 to 18, one finds that the risk is highest during the first year. Subsequently, this has a significant statistical impact on the mean life expectancy of the whole population.

Joachim Winter: In Europe, the death rate in the poorest districts over the 28 years that we analyzed has fallen by one third. This is a development that began towards the end of the 19th century with the professionalization of hospitals, and continued into the early years of the 20th century thanks to further revolutionary advances in the treatment of illnesses and in medical care in general. This trend has essentially continued since then. Improved environmental conditions and the widespread adoption of healthier lifestyles have also played a role.

How has the factor ‘life expectancy’ developed in the US relative to Germany?

Peter Redler: Even before the arrival of the coronavirus pandemic, it had become clear that mortality rates in certain age groups in the US had begun to rise again. This is attributable largely to what has been called ‘deaths of despair’. This category includes the opioid epidemic in the United States There has not been a similar crisis in Europe.
Our study also shows that the degree of inequality, as measured by the difference in mean income between the poorest 5% and the richest 5% of the population is higher in the US. The mortality rates there are more strongly correlated with socioeconomic status. However, levels of inequality are also falling over time.

Joachim Winter: Indeed, the difference between the mortality rates for Blacks and Whites in the US has been significantly reduced in recent decades. But inequalities between the poor and the rich remain, and on average Blacks still die at an earlier age than Whites. But the improvement in life expectancy has tended to favor the disadvantaged. It’s possible that this trend will reach a limit at some point. Nevertheless, the fact that the gap in life expectancy is closing is a fundamentally positive development. Recently, however, the debate over mortality rates in the US has begun to focus on the fact that life expectancy for the White population is no longer rising. We compared these developments with the situation in Europe, and our study shows that, in contrast to the US, life expectancy in Europe has continued to rise – at least up until 2015.

Research on the long-term determinants of health

In your Department, you not only evaluate the development of social inequality and life expectancy, you also carry out studies of individual behavior. How are these studies linked together?

Joachim Winter: My research has focused on the long-term determinants of health. One such determinant is shocks to which children are exposed at a very young age or even in-utero. Such shocks can be caused by external factors – and we have focused particularly on periods of hunger that occurred soon after the World War II, which of course had long-term effects on child development. But certain elements of parental behavior can also have long-term consequences for the health of their children. Generally speaking, people who are better educated are more likely to take better care of their own and their children’s health. That in turn leads to long-term developments which cannot be easily reversed. Economic status, living conditions, and behavioral patterns are all factors that come into play in this context. We investigate the links between socioeconomic status on the one hand and health on the other.

In many countries, particularly the USA, access to the health system is very unequally distributed between the different socioeconomic groups. That is in large part due to the lack of health insurance for relatively poor individuals, although the situation has been improved by Obamacare and other reforms of the American health system. In Germany, access to the health system is not such a serious problem. Thanks to our health insurance system, access to basic care is guaranteed. In Germany, the link between one’s socioeconomic background and life expectancy is influenced not by the health system itself, but environmental and behavioral factors. Health behaviors, such as eating healthy, as well as health utilization, such as when to use health services like cancer screening, play a large role.

Your work shows that one’s socio-economic status has a significant influence on personal health. However, in healthcare systems there is an increasing tendency to reward individual health-promoting behavior. Health insurers award bonus points for certain measures, for example. How do you view this development?

Joachim Winter: In principle, incentives are a sensible way of motivating people to adopt a healthy lifestyle, but they cannot fix all the problems. Some studies, in which we were not involved, show that those who are most likely to respond to incentives are those who already behave in a manner that is comparatively beneficial to health maintenance. Conversely, those who are less likely to respond to incentives – for whatever reasons – are those who are more difficult to motivate. There is also some debate on whether, and if so, how insurance companies exploit incentives to their own advantage. This is why the whole issue of incentives is highly regulated in Germany.

Peter Redler: In our work on Germany, we also assessed which socioeconomic groups have gained most from the overall increase in life expectancy over the past 15 years. It turns out that contrary to the 1990s, the greatest gains have come in areas with higher levels of income. So there is likely a lot of potential for an increase in life expectancy in districts with lower mean incomes.

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You have analyzed data for Germany over the period from 1990 to 2015. Can you say anything about what has happened during the last five years?

Peter Redler: In our context, our numbers for 2015 represent a weighted average of the period 2014-2016. In other words, it’s based on cumulative data for three years. The scope of our studies did not include the pandemic yet.

Joachim Winter: The data for administrative districts are made available to researchers only after some delay. But for Germany as a whole, it is already evident that life expectancy has risen further since 2015. As a result of the Covid-19 pandemic, it very probably fell somewhat in 2020. But these developments cannot be compared with the dramatic weakening of the positive long-term trends in life expectancy in the US. Germany has not been afflicted by an opioid crisis, for instance.

Peter Redler: But it also has to be said that life expectancy is no longer rising as fast as it previously has. Mortality rates are falling more slowly. This is a trend which can also be observed in places where life expectancy is very high, such as Japan and the Northern European countries. In those regions where life expectancy has risen fastest, the rate of progress is now slowly falling off, and other areas are catching up.

Joachim Winter: It will be interesting to see how the trajectory of life expectancy develops in the coming years. In the next 10 years, the majority of those who die will be those who were born after the Second World War. So the very difficult conditions that prevailed during and after the war years will no longer be relevant. This in itself will contribute to a further decrease in mortality rates for the oldest age cohorts. And one then has to factor in the continuing improvements in the provision of healthcare. New breakthroughs in cancer therapies would of course have an immense impact on mortality rates and life expectancy.

Interactions between various types of inequality

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How do you intend to further analyze these issues?

Joachim Winter: We will continue to investigate the causes of the uneven development of life expectancy. For example, we want to take a closer look at whether the significant increase in mortality in East Germany, which persisted well into the 1990s, is connected to environmental pollution – which is a promising hypothesis. However, to do that, we will need more detailed data on the spatial distribution of air pollution in the GDR prior to reunification.

A larger research project will address the question of the interactions between various types of inequality. In the two studies we have talked about here, we looked at the relation between income inequality and mortality. But there are other dimensions of inequality to be considered, in particular in relation to education, which has an influence on both income levels and health-related behavioral patterns. One can think of these connections in terms of a triangle whose corners are education, income and health. It is vital to understand the causal relationships between these three dimensions of inequality. It would be very helpful in this context if these data could be better collected and connected in Germany. Many of our current findings in this area are based on Scandinavian or American data. We hope that Germany will improve access to, and connectivity of data in official registries and other data sources, such as opinion surveys, for instance.

Redler P., Wuppermann A., Winter J., Schwandt H., Currie J. Geographic Inequality in Income and Mortality in Germany. Fiscal Studies (2021). Doi: 10.1111/1475-5890.12259

Schwandt H. et al. Inequality in mortality between Black and White Americans by age, place, and cause and in comparison to Europe, 1990 to 2018. PNAS (2021). doi: 10.1073/pnas.2104684118