International Journal of Social Determinants of Health and Health Services

A growing body of evidence documents how economic crises impact aspects of health across countries and over time. We performed a systematic narrative review of the health effects of the latest economic crisis based on studies of high-income countries. Papers published between January 2009 and July 2015 were selected based on review of titles and abstracts, followed by a full text review conducted by two independent reviewers. Ultimately, 122 studies were selected and their findings summarized. The review finds that the 2008 financial crisis had negative effects on mental health, including suicide, and to a varying extent on some non-communicable and communicable diseases and access to care. Although unhealthy behaviors such as hazardous drinking and tobacco use appeared to decline during the crisis, there have been increases in some groups, typically those already at greatest risk. The health impact was greatest in countries that suffered the largest economic impact of the crisis or prolonged austerity. The Great Recessions in high-income countries have had mixed impacts on health. They tend to be worse when economic impacts are more severe, prolonged austerity measures are implemented, and there are pre-existing problems of substance use among vulnerable groups.

Austerity policies implemented in Spain in response to the ongoing economic crisis may have detrimental consequences for the health of immigrant populations and for public health in general. A mixed-methods study by the Public Health Agency of Barcelona and the University of Michigan indicates that the Real Decreto-ley 16/2012 (RDL) threatens the health of individuals and the population, especially in the case of infectious diseases. The study sought to determine the percentage of foreign-born persons with an infectious disease who had an Individual Health Card (IHC) prior to the RDL and to determine whether foreign-born persons with an infectious disease in Barcelona encountered problems accessing health care after the RDL. Results indicate that immigrants used the IHC to seek medical attention for infectious diseases and chronic conditions. Results also show that 66% of respondents, including 54% of unemployed respondents, 3% of respondents working without contracts, and those in informal employment (9%), may be at risk of losing at least part of their health coverage. Universal health care access in Spain has been crucial for the control of communicable diseases among immigrant populations. Reducing access to a significant percentage of the total population may have deleterious effects on public health.

We argue that the political economy of health care in the European Union is being changed by the creation of a substantial new apparatus of European fiscal governance. A series of treaties and legal changes since 2008 have given the European Union new powers and duties to enforce budgetary austerity in the member states, and this apparatus of fiscal governance has already extended to include detailed and sometimes coercive policy recommendations to member states about the governance of their health care systems. We map the structures of this new fiscal governance and the way it purports to affect health care decision making.

The current financial crisis has seen severe austerity measures imposed on the Spanish health care system, including reduced public spending, copayments, salary reductions, and reduced services for undocumented migrants. However, the impacts have not been well-documented. We present findings from a qualitative study that explores the perceptions of primary health care physicians in Madrid, Spain. This article discusses the effects of austerity measures implemented in the public health care system and their potential impacts on access and utilization of primary health care services. This is the first study, to our knowledge, exploring the health care experiences during the financial crisis of general practitioners in Madrid, Spain. The majority of participating physicians disapproved of austerity measures implemented in Spain. The findings of this study suggest that undocumented migrants should regain access to health care services; copayments should be minimized and removed for patients with low incomes; and health care professionals should receive additional help to avoid burnout. Failure to implement these measures could result in the quality of health care further deteriorating and could potentially have long-term negative consequences on population health.

Recommodification, the withdrawal of social welfare, has been going on for some decades in both Sweden and England. Recommodification disproportionately affects the unemployed because of their weak market position. We investigated the impact recommodification has had on health inequalities between the employed and unemployed in Sweden and England. Using national surveys, odds ratios for the likelihood of reporting less than good health between the employed and unemployed were computed annually between 1991 and 2011. The correlation between these odds ratios and net replacement rates was then examined. Health inequalities between the employed and unemployed were greater in 2011 than in 1991 in both countries. Sweden began with smaller health inequalities, but by 2011, they were in line with those in England. Sweden experienced more recommodification than England during this period, although it started from a much less commodified position. Correspondingly, correlation between unemployment benefit generosity and health inequalities was stronger in Sweden than in England. Recommodification is linked to ill health among the unemployed and to the health gap between the employed and unemployed. We propose that further recommodification will be associated with increased health inequalities between the employed and unemployed.

U.S. employment-based health benefits are exempt from income and payroll taxes, an exemption that provided tax subsidies of $326.2 billion in 2015. Both liberal and conservative economists have denounced these subsidies as “regressive” and lauded a provision of the Affordable Care Act—the Cadillac Tax—that would curtail them. The claim that the subsidies are regressive rests on estimates showing that the affluent receive the largest subsidies in absolute dollars. But this claim ignores the standard definition of regressivity, which is based on the share of income paid by the wealthy versus the poor, rather than on dollar amounts. In this study, we calculate the value of tax subsidies in 2009 as a share of income for each income quintile and for the wealthiest Americans. In absolute dollars, tax subsidies were highest for families between the 80th and 95th percentiles of family income and lowest for the poorest 20%. However, as shares of income, subsidies were largest for the middle and fourth income quintiles and smallest for the wealthiest 0.5% of Americans. We conclude that the tax subsidy to employment-based insurance is neither markedly regressive, nor progressive. The Cadillac Tax will disproportionately harm families with (2009) incomes between $38,550 and $100,000, while sparing the wealthy.

On September 27, 2014, Swiss voters rejected a proposal to replace their system of about 60 health insurance companies offering mandatory basic health coverage with a single public insurer, the state, which would offer taxpayer-funded coverage of all medically necessary care. The Swiss and the U.S. media, academia, and business sectors, from conservative and liberal camps, interpreted the results to mean a rejection of single payer and a preference for a privately run system, with important implications for health reform in the United States. While on the surface mainstream interpretations appear reasonable, I argue that they have little basis on fact because they rely on assumptions that, while untrue, are repeated as mantras that conveniently justify the continuation of a model of health insurance that is unraveling, less conspicuously in Switzerland, dramatically in the United States. To make my case, I describe the dominant narrative about Swiss health care and mainstream interpretations of the latest referendum on health reform, unpack the problem within these interpretations, and conclude by identifying what lessons the Swiss referendum contains for single payer advocates in the United States in particular and for those who struggle for social and economic rights more generally.

The Lancet–University of Oslo Commission Report on Global Governance for Health provides an insightful analysis of the global health inequalities that result from transnational activities consequent on what the authors call contemporary “global social norms.” Our critique is that the analysis and suggested reforms to prevailing institutions and practices are confined within the perspective of the dominant—although unsustainable and inequitable—market-oriented, neoliberal development model of global capitalism. Consequently, the report both elides critical discussion of many key forms of material and political power under conditions of neoliberal development and governance that shape the nature and priorities of the global governance for health, and fails to point to the extent of changes required to sustainably improve global health. We propose that an alternative concept of progress—one grounded in history, political economy, and ecologically responsible health ethics—is sorely needed to better address challenges of global health governance in the new millennium. This might be premised on global solidarity and the “development of sustainability.” We argue that the prevailing market civilization model that lies at the heart of global capitalism is being, and will further need to be, contested to avoid contradictions and dislocations associated with the commodification and privatization of health.

For nearly 30 years, Mozambique has been facing austerity measures regulated by the IMF. These austerity measures, grounded in macroeconomic policies, were supposed to lift Mozambique out of poverty, and improve its healthcare and education systems. By taking an in-depth look at the major etiologies of Mozambique’s debt and the conditions which forced the country to accept austerity measures-despite their protests-prior to receiving IMF funding, this paper examines how IMF policies over the past 30 years have affected poverty, health, and the education system. The results of these policies have contributed to Mozambique’s enduring classification as one of the poorest countries in the world. Aside from economic outcomes, Mozambique also has abysmal health and education systems, with one of the lowest life expectancies in Sub-Saharan Africa. It is time to re-evaluate how the current IMF macroeconomic policies negatively affect, health, education and the socioeconomic status of those who live in abject poverty. As short term macroeconomic policies of PARPA have been ineffective at reducing poverty, promoting education and improving health, the IMF should consider using longer term macroeconomic policies which invest in—rather than limit—public services such as health and education.