Unjust Health Inequalities : An Analysis Based on Canada ’ s National Population Health Survey and the HealthPaths Microsimulation Model

Discussions of the fairness or justice of health inequalities has tended to cluster into two relatively separate literatures – one empirical, the other philosophical. In the empirical literature, the preponderance of concerns regarding health inequalities is with the social patterning of health, the ubiquitous observation that higher socio-economic status, however measured, is associated with better health, also measured variously. The (often implicit) judgment is that this correlation is intrinsically unfair. The philosophical literature, in contrast, looks to the sources or causes of health inequalities – with some sources judged unfair, such as those which are clearly remediable, and others not. However, the empirical literature tends to be weak on explicit moral reasoning, while the philosophical literature typically does not include any empirical analysis. In this paper, we endeavor to bring these two strands together. The key innovation enabling this bridging of the two literatures is a microsimulation model, HealthPaths. HealthPaths is based on and tightly coupled to a very intensive multiple equation statistical analysis of the dynamics of individuals’ health and key covariates based on the longitudinal Canadian National Population Health Survey with linked mortality follow-up. This analytical machinery therefore embodies best current quantification of many of the main elements of the “web of causality” for Canadians’ health. In turn, by simulating counter-factual scenarios, HealthPaths can generate health distributions “as if” a given source of health inequalities were absent. 1 We are indebted to the members of the NIH-funded Network on Inequality, Complexity and Health for valuable discussion. This work has been funded by the Canadian Foundation for Innovation. 2 Skipper quoted in Mukherjee (2010); Marmot (2013)