Indirect Effects of Policy

The policy possibilities we have considered are limited in an important respect. A broader conception of the possibilities would include any government measure that results in some transfer of resources, as well as other government regulations that, intentionally or not, affect health differences or the factors underlying them. Though such policies may be adopted for reasons unrelated to health, they may have important indirect effects on health differences.

Since socioeconomic factors have an important relationship to health differences, any program that affects resource distribution in the society could have health implications. For instance, changes in Medicare funding could affect health differences. As noted above, exclusive dependence on Medicare is higher among Hispanics and blacks than among whites, so that changes in the program could have more effects on them. Given the known and hypothesized effects on health in late life of childhood conditions, one may consider racial and ethnic differences in the socioeconomic conditions of childhood and government programs that exacerbate those effects or do not attempt to remedy them (Warner and Hayward, 2002).

Changes in immigration regulations could also affect health differences, by affecting the number, selectivity, or experience of the recent immigrants who constitute an important proportion of some racial and ethnic groups. Tighter controls on immigration, for instance, could increase the risks that illegal immigrants take, reduce the propensity for circular migration and therefore modify salmon bias (the return to their native countries of ill immigrants), and make immigrants a more select group in ways that could have unpredictable implications for population health.

National policy may in fact have had substantial influence on health differences from the 1960s to the 1990s. From 1968 to 1978, blacks showed larger gains than whites in life expectancy and larger declines in mortality rates from a variety of causes (Cooper et al., 1981). But from 1980 to 1991, the black-white gap in health status widened, whether measured by life expectancy, excess deaths, or infant mortality (National Center for Health Statistics, 1994; Williams and Collins, 1995), before narrowing again in the 1990s. The trends in the mortality gap also appeared at older ages, among those aged 65-74 (National Center for Health Statistics, 2003). The narrowing of the gap in the late 1960s and the early 1970s coincided roughly with gains from the civil rights movement and a parallel narrowing in the income gap between blacks and whites (Economic Report of the President, 1998; Williams, 2001a). The reversal of the trend in health differences beginning around 1980 coincided with substantial changes in national social and economic policies, during which the health status of economically vulner-



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