Disparate Aging: The Role of Education and Socioeconomic Gradients in Future Health and Disability in an International Context

Population aging is a critical policy challenge to advanced economies around the world. There were 703 million persons aged 65 years or over in the world in 2019. The number of older persons is projected to double to 1.5 billion in 2050. The share of the population aged 65 years is expected to rise from 9 percent today to 16 percent by 2050. Put another way, one in six people in the world will be aged 65 years or over (United Nations, 2015a2015b2015c).

These trends pose both fiscal and population health challenges, principal among these being the persistent and large socioeconomic gradients in health. Many older persons retain overall good health and functioning well into old age, but—in the context of rapid population aging—disparities can be exacerbated. Some of these differences are attributable to genetics, but other policy mutable factors play an important role: factors such as the natural and physical environment (air pollution and accessibility), risky behaviors (drinking, smoking and physical inactivity), and individual characteristics such as occupation and level of income. Therefore, if on one side aging is driven by biological changes, on the other side the ageing itself reflects the accumulated effects of one’s exposure to a history of external risks, and can further be influenced by social changes, such as isolation and loss of loved ones. The end result is often a complex combination of both individual characteristics and other health determinants; hence, health disparities at older age often reflect accumulated disadvantage.

There is an emerging, increasing and widespread consensus about the positive role that education can have in reducing this accumulated disadvantage. This advantage is believed to occur mostly because education behaves as an enabler, which helps individuals to use more properly the inputs in the health production function (Grossman, 197219752000). In this way several factors contribute to the role of education in influencing health outcomes. Social and biological processes initiated in early life influence both educational achievement and adult health. Education has a direct and indirect role in driving the relationship between socio-economic status (SES) and health. Better education increases the chances to pursue personal and professional success, which in turn determine socio-economic outcomes such as access to better occupational positions and higher incomes. As such, education has an indirect influence on health by giving the possibility to improve the allocation of resources and invest more heavily in health. However, labor market participation and higher incomes that better educated individuals earn are only a partial explanation behind the indirect education-health link (Brunello et al., 2015, Grossmann and Kaestner, 1997). Education enables individuals to be more efficient in maintaining good health (Grossman, 1972) by prompting them to make better health choices (Brunello et al., 2015, Rosenzweig and Schultz, 1983), increasing their willingness and ability to access and use information (Goldman et al., 2015), and increasing their investment in social capital. The direct impact is associated with productive abilities, which help individuals act more effectively as agents by fostering generic skills such as information-gathering and decision-making. This direct aspect of education, learned effectiveness, promotes sense of control, developing habits of preventing and solving problems, regardless of available resources and prevailing conditions. Ruhm (2012) suggests that cognitive functioning and the resulting deliberative abilities contribute to a correct evaluation of long-run implications of lifestyle choices. Put differently, as suggested by Kenkel et al. (2006), better education enables individuals to obtain superior health outcomes from a fixed set of inputs, due to the better choices they make.

It then follows that education improves health conditions and reduces health disparities (see Cutler and Lleras-Muney, 2008; Cutler and Lleras-Muney, 2010, Glaeser et al., 2000, for reviews) through different channels. Educational attainment is a particularly profound predictor of length of life, now surpassing both race (Harper et al., 2007; Kochanek et al., 2013) and gender (Arias, 2007; Rogers et al., 2010) in importance in the United States. Furthermore, a large literature has documented substantial associations between education and mortality, health (self-reported health, obesity, etc.) and health behaviors (smoking, excessive drinking, exercise, preventive care use, etc.). These relationships exist but vary in magnitude across countries. In the United States, those at age 25 with more than a college degree can expect to live up to seven years longer than those without a college degree (Meara et al., 2008; Hummer and Hernandez, 2013). It should be noted, however, that some studies (Clark and Royer, 2013; Behrman et al., 2011) find no causal impact of schooling on health.

Educational differences in life expectancy have also widened since the 1980s, across all major race and gender groups (Goldman and Smith, 2011; Olshansky et al., 2012) and in all regions of the United States (Montez and Berkman, 2014). According to Chetty et al. (2017), inequality in life expectancy increased between 2001 and 2014 (by 2.34 years for men and 2.91 years for women in the top 5% of the income distribution, which is a good proxy of education level), but by only 0.32 years for men and 0.04 years for women in the bottom 5%. Furthermore, those with less than a high school diploma exhibit higher lifespan variability and can expect greater uncertainty in their time of death (Brown et al., 2012; Edwards and Tuljapurkar, 2005; Sasson, 2016). By contrast, college-educated Americans live longer, on average, and exhibit greater compression of mortality, with deaths narrowly concentrated at the upper tail of the age distribution—a pattern similarly observed in several European countries (van Raalte et al., 2011).

This study was published as a special issue of Health Economics.