Education and Health Across Lives, Cohorts, and Countries

198 Pages·2017·1.31 MB·English

Education and Health
Across Lives, Cohorts, and Countries
A Study of Cumulative (Dis)advantage in
Germany, Sweden, and the United States
Liliya Leopold

Thesis submitted for assessment with a view to
obtaining the degree of Doctor of Political and Social Sciences
of the European University Institute
Florence, 04 May 2017
European University Institute
Department of Political and Social Sciences
Education and Health Across Lives, Cohorts, and Countries
A Study of Cumulative (Dis)advantage
in Germany, Sweden, and the United States
Liliya Leopold

Thesis submitted for assessment with a view to
obtaining the degree of Doctor of Political and Social Sciences
of the European University Institute
Examining Board
Professor Hans-Peter Blossfeld (EUI, Supervisor)
Professor Fabrizio Bernardi (EUI)
Professor Johan Mackenbach (Erasmus Medical Center, University of Rotterdam)
Professor Johan Fritzell (CHESS, University of Stockholm)

© Liliya Leopold, 2017
No part of this thesis may be copied, reproduced or transmitted without prior
permission of the author
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Department of Political and Social Sciences - Doctoral Programme
I Liliya Leopold certify that I am the author of the work "Education and Health
Across Lives, Cohorts, and Countries: A Study of Cumulative (Dis)advantage in
Germany, Sweden, and the United States" I have presented for examination for the
Ph.D. at the European University Institute. I also certify that this is solely my own
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issued by the European University Institute (IUE 332/2/10 (CA 297).
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I confirm that chapter 4 was jointly co-authored with Dr. Thomas Leopold and I
contributed 80% of the work.

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This thesis has been corrected for linguistic and stylistic errors. I certify that I have
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21.02.2017
Abstract

According to the cumulative (dis)advantage hypothesis, social disparities in health increase over
the life course. Evidence on this hypothesis is largely limited to the U.S. context. The present
dissertation draws on recent theoretical and methodological advances to test the cumulative
(dis)advantage hypothesis in two other contexts – Sweden and West Germany. Three empirical
studies examine the core association between socioeconomic position and health (a) from a life-
course perspective considering individual change, (b) from a cohort perspective considering socio-
historical change, and (c) from a comparative perspective considering cross-national differences.
The analyses are based on large-scale longitudinal data from the Swedish Level of Living Survey,
the German Socio-economic Panel Study, the Health and Retirement Study, and the Survey of
Health, Ageing and Retirement in Europe. The key analytical constructs are education as a measure
of socioeconomic position and self-rated health, mobility limitations, and chronic conditions as
measures of health.
The results show large differences within countries and between countries in the age patterns
and cohort patterns of change in health inequality. In the U.S., educational gaps in health widen
strongly over the life course, and this divergence intensifies across cohorts. In Sweden, health gaps
are much smaller, widen only moderately with age, and remain stable across cohorts. In Germany,
health gaps widen with age and across cohorts, but these patterns pertain only to men.
Taken together, these findings show that health inequality across lives and cohorts is
mitigated in Western European welfare states, which target social inequality in health-related
resources. In the U.S. context, which is characterized by a lack of social security, unequal access
to health care, and large social disparities in quality of living, health inequality increases across
lives and cohorts.

1
Publication record and declaration of the author’s contribution to the studies
contained in this dissertation
(as of February, 2017)

Study I
“Cumulative Disadvantage in an Egalitarian Country? Socioeconomic Health Disparities over the
Life Course in Sweden”, Journal of Health and Social Behavior 2016, 57: 257-273.

Sole authorship.

Study II
“Education and Health in the United States and Sweden:A Comparative View on Health
Trajectories in Later Life”, Revise & Resubmit at Demography.

Sole authorship.

Study III
“Education and Health Across Lives and Cohorts: A Study of Cumulative (Dis)advantage in
Germany”, Revise & Resubmit at Journal of Health and Social Behavior.

Contribution of Liliya Leopold is approximately 80%. Co-authored with Thomas Leopold.

An earlier draft of this Chapter has been published as a working paper: Leopold, L., and T.,
Leopold. 2016. “Education and Health Across Lives and Cohorts: A Study of Cumulative
Advantage in Germany”, SOEPpapers No. 835 – 2016.

2
Contents

Chapter I
Introduction.....………………………………….…:…………….…………………………4

Chapter II
Cumulative disadvantage in an egalitarian country?
Socioeconomic Health Disparities over the Life Course in Sweden..………:….………...41

Chapter III
Education and Health in the United States and Sweden:
A Comparative View on Health Trajectories in Later Life………………:………………83

Chapter IV
Education and Health Across Lives and Cohorts:
A Study of Cumulative (Dis)advantage in Germany……………………………………121

Chapter V
Discussion ………………..………………………………………………….…………:178

3
Chapter I
Introduction

Health is one of the most important goods for individuals and societies. Being healthy is a
precondition for achieving personal goals and fulfilling social roles. The societal benefits of
improving population health and prolonging lives include not only reductions of health care
expenditures, but also increases in productivity, labor supply, and economic growth (Bloom and
Canning 2000).
Despite its immense value, large social groups still fail to maintain good health. Remarkably,
this is not only the case in poor countries, but even in the most developed societies where the basic
needs for being healthy – sufficient nutrition, medical supply, and adequate housing – have long
been covered for the majority of the population (Fritzell et al. 2013; Marmot 2005; Mackenbach
2012). Moreover, substantial variation in the extent of social disparities in health exists not only
between poor and rich countries, but also within the most advanced democracies (Smits and
Monden 2009). In the U.S., for example, disparities between the least and the most affluent and
educated people in mortality, physical functioning, and chronic conditions greatly exceed those in
Western European countries. However, health disparities are substantial also in Western Europe.
For instance, the gap between lower and higher educated people in disability-free life expectancy
amounts to eight years; the probability of being in good self-rated health amounts to about 30
percentage points (Hu et al. 2016; Mäki 2013; Mackenbach 2008). Although the most recent studies
report positive trends of declining social inequality in mortality, substantial disparities in health
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