Introduction to Health Economics and Policy Term Paper:

Health and Education

Ivan Srbulov

January, 2017

1 Introduction
Although seemingly obvious, there is quite a bit of depth to the question of whether
education can improve health, reduce mortality, and increase life expectancy. The mor-
tality rates of people with no secondary school diploma is up to twice of those with some
university education[1].

“An additional four years of education lowers five year mortality by 1.8 per-
centage points; it also reduces the risk of heart disease by 2.16 percentage
points, and the risk of diabetes by 1.3 percentage points. Four more years
of schooling lowers the probability of reporting in fair or poor health by 6
percentage points, and reduce lost days of work to sickness by 2.3 each year.
[...] the magnitude of 4 years of schooling is roughly comparable in size to
being female or being African American. These are not trivial affects.”[2]

So, while these things are correlated, are they connected? Does education matter to
our health, and how? There are three plausible explanations for the education effect,
firstly that “[...]there is a causal relationship between schooling and health. [Secondly],
that the direction of causality is reversed. [Third], that there is no causal relationship
implied by the observed correlation between education and health.”

2 Health as a confounder: Wealth, Income, and Careers

2.1 Wealth, the sheepskin effect, and access to healthcare and hygiene
products
An obvious speculative answer is that the educated tend to work in higher-paying jobs,
and hence have more money to spend on healthier food, insurance, and other health-
related consumption goods. This is supported by a simultaneous increase in “health
returns to education in the 1980s and 1990s at the same time that the labour returns
to education were rising.”[9] However, even in this case, when income, marital status,
ethnicity and health insurance is controlled in the data it still only accounts for one third

1
of the difference: there is still an educational effect[2]. Additional evidence shows that
when even job occupations are controlled, those with an education are healthier than
those without[2][3].
Whilst poverty most certainly has a negative effect on health, wealth is not the
explanation. This is explained by the lack of a sheepskin effect in health as there is in
the labour market: graduates earn a lot more money the moment they graduate, however
graduate health and mortality doesn’t have such a drastic change simply due to having
the degree. If income was the explanation, there would be a sharp change between final
year students and graduates; however, the relationship between the penultimate, final,
and graduate students is linear in almost all areas. In fact, the effect on healthcare is
linear after the 10th year of education (i.e Year 11 students who will be taking their
GCSEs), unlike earnings would be[2].
Furthermore, the health benefits of (or related to) an education diminish after 50
years old[2]. In the model that health increases with wealth, this does not follow as this
is when many adults reach peak earnings and have the most stable jobs. Additionally,
no amount of money can save anybody from death or the many illnesses that occur
naturally with old age: only exercise and good decisions during formative years can
delay these ailments which requires planning and an investment in oneself.
Additionally, to further prove that income is not as important to health as one as-
sumes, Cutler and Lleras-Muney show that the impact of education on health is actually
biggest to individuals which come from families above $20,000pa. This suggests that
income is complementary to education–i.e the means to buy healthcare–rather than the
reason for good health[2].

2.2 Intelligence and educated decisions

Research shows that people with four more years of education (i.e university graduates)
“have healthier behaviours “almost unanimously: “Those with more years of schooling
are less likely to smoke, to drink a lot, to be overweight or obese, or to use illegal drugs.
Interestingly, the better educated report having tried illegal drugs more frequently, but
they gave them up more readily.”[2]
The latter point is particularly interesting, as it suggests that the costs of continu-
ing consuming the drugs/the addiction outweighs the benefits and enjoyment the user
receives to the point where any potential withdrawal symptoms are not a barrier. This
is rational considering some of the effects of drug addiction include losing jobs, criminal
convictions, and the biological effects of drug use could ruin a future that they see as
being very valuable and full of potential.
Further to the point, the wider drug use suggests that educated people are more
curious and open to new things which could mean faster adoption of scientific research
and technology: 71% of those with a degree thought that new technology was beneficial
despite potentially harmful results compared to just 25% of those without a high school
diploma. This might be because “they are more likely to understand the nature of
scientific enquiry.”[2][4]. For example, the educated were one of the first to quit smoking
after the 1964 Surgeon General Report[5]. With smoking today, although most people

2
know of the affects and risks, the uneducated continue to smoke the most, implying that
the decisions educated people make goes beyond information and knowledge[6][7]:

“Education might matter for health not just because of the specific knowledge
one obtains in school, but rather because education improves general skills,
including critical thinking skills and decision-making abilities.”[2]

Additionally, educated people “are more likely to exercise and obtain preventative
care such as flu shots, vaccines, mammograms, pap smears, and colonoscopies. Among
those with chronic conditions such as diabetes and hypertension, the more educated are
more likely to have their condition under control. Furthermore, they are more likely to
use seat belts and to have a house with a smoke detector and that has been tested for
radon.” This also proves that, in other and more mundane topics, educated people are
more responsible and willing to invest in their future.
This supports my hypothesis above, in that the value of their future is worth the
due care and attention that they give at the present. When looking at this through the
Beta-Delta discounting model, it’s clear that educated people value their future more
than those without an education[8]. Perhaps, in addition to educated people valuing
their futures more, it’s possible that those without education have little incentive to do
so, on average, meaning that ways to enjoy themselves now are far more useful to them
than a future without much to look forward to[2]. However, this theory is difficult to
test and so we cannot know its significance.
It is possible that, in this case, education is simply used analogously to intelligence.
Intelligent people tend to make ‘intelligent’ decisions, such as wearing seatbelts and
looking after their bodies, but also getting an education for its virtuous and economic
value[10]. The iconic Stanford marshmallow experiment proved that children which had
a good understanding and also appreciation for increased total earnings in the future
compared to present preferences (i.e a second marshmallow for waiting 20 minutes)
tended to achieve higher SAT scores and were more likely to attend a university[11]. It’s
also possible that higher education can lead to even lower discount rates, magnifying the
effect[10][12].
As such, there is evidence to suggest that intelligent people want to invest in them-
selves and their future; an education and a healthy body are often the two most impor-
tant things and it is not surprising that they are correlated.

2.3 The spillover effect

The positive healthcare effects of education spread to spouses, parents, and children. For
example, mothers with more education tend to have healthier babies[13]. Uneducated
parents of educated children also received benefits, with one paper showing that these
parents were more likely to quit smoking[14]. Furthermore, uneducated spouses some-
times have lower mortality rates, better health, and partake in fewer unhealthy habits
like drinking and smoking[15][16][17][18]. In this case, we see that it is education and
not wealth or any other confounding variables that benefit people. However, education

3
is still a medium with which to see individuals who make better decisions and value the
future more than their uneducated children, parents, or spouses. While this interesting
nuance only complicates the question, it should not be ignored.

3 Education as a direct contribution to health

3.1 Forced attendance
The argument that I outlined in the “Intelligence and educated decisions” section, in
short, states that intelligent people tend to get an education and invest in themselves
and in their future, including healthcare. This explained the reason why people with
more education tended to have better health and lower mortality rates.
However, that would not account for data that shows schoolchildren who were forced
to attend additional years of education due to policy changes in England, Ireland, the US,
Denmark, and Sweden all had improved health and lower mortality rates[19][20][21][22].
The consistency of the effect over a variety of countries negates other possible policy
changes that could impact health. This implies that even when education is forced it
provides health benefits, negating the causal theories of self-investment and intelligence.
Despite this, there still is no clear causal argument as to why education makes a
direct difference to health; research into “the causality between education and health
within a specific country [has] generated different results.”[23] However, Cross makes an
attempt to statistically prove the link in a regression equation that takes into account
several variables and deals with education being either an endogenous or exogenous
variable[23]. He shows that for 75% of the analysed ailments there is positive and statis-
tically significant evidence between education and healthcare, all things considered, with
the educational effect being “larger than the Probit estimates [can explain] alone.”[23].
Cross claims that “the relationship between education and reporting poor health is very
robust and most likely to be causal.”[24]

3.2 Breast cancer

On the other hand, whilst there are casual arguments as to why health can lead to
better education, leading to questions about reverse causality, it cannot account for
mandatory education effects and also that cancer diagnosis and mortality rates are higher
in educated women[23]. This is uniquely true of breast cancer, as instances of cervical
cancer decrease with education[25].

4 Summary
Current research and literature suggests that, with few explicable exceptions, healthcare
does improve with education due to the positive socio-economic effects and, with plau-
sible evidence, because of it. The exceptions, like breast cancer, succeed in providing
evidence of a causal relationship. Education can be used as a confounding variable that

4
is analogous for a variety of exogenous factors like wealth, access to infrastructure, and
intelligence. Either way, it is clear that more education will increase one’s probability of
being healthier and living longer.

References
[1] Table 26, National Vital Statistics Report, 2001

[2] David M. Cutler; Andriana Lleras-Muney, Education and Health: Evaluating Theo-
ries and Evidence, June 2006

[3] E. Lahelma et al. “Pathways between socioeconomic determinants of health,” 2004

[4] National Science Foundation, Science and Engineering Indicators, 2000

[5] D. de Walque “How does the impact of an HIV/AIDS information campaign vary
with educational attainment? Evidence from Rural Uganda 2005

[6] E. Meara “Why is Health Related to Socio-Economic Status? The Case of Pregnancy
and Low Birth Weight,” 2001

[7] D. Kenkel “Health Behaviour, Health Knowledge and Schooling,” 1991

[8] Kevin M. Murphy; Robert H. Topel “The Value of Health and Longevity” 2005

[9] David Autor; Lawrence F. Katz; Melissa S. Kearney Trends in U.S. Wage Inequality:
Re-Assessing the Revisionists 2005

[10] Victor R. Fuchs “Time Preference and Health: An Exploratory Study” 1982

[11] Mischel, Walter; Ebbesen, Ebbe B.; Raskoff Zeiss, Antonette, Cognitive and at-
tentional mechanisms in delay of gratification, Journal of Personality and Social
Psychology, Vol 21(2), Feb 1972, 204-218

[12] Gary S. Becker; Casey B. Mulligan “The Endogenous Determination of Time Pref-
erence,” 1997

[13] Anne Case; Angela Fertig; Christina Paxson “The Lasting Impact of Childhood
Health and Circumstance” 2005

[14] Elrica Field “Are there upwards intergenerational education spillovers on health?
The impact of children’s education on parents’ smoking cessation,” 2005

[15] G. M. Egeland et al “A man’s heart and a wife’s education: 12 year coronary heart
disease mortality follow-up in Norwegian men,” 2002

[16] Bosma et al. “Education level of spouses and risk of mortality,” 1995

[17] L Suarez; E. Barrett-Connor “Is an educated wife hazardous to your health?” 1984

5
[18] Christian W.S. Monden et al “Partner’s sown education: Does who you live with
matter for self-assessed health, smoking and excessive alcohol consumption?” 2003

[19] A. Lleras-Muney “The Relationship Between Education and Adult Mortality in the
United States,” 2005

[20] Philip Oreopolous “Do Dropouts Drop Out Too Soon? Wealth, Health, and Hap-
piness from Compulsory Schooling,” 2003

[21] J. N Arendt “Does Education cause better health? A panel data analysis using
school reform for identification.” 2005

[22] J. Spasojevic “Effects of education on adult health in Sweden: results from a natural
experiment,” 2003

[23] Roquel Fonseca; Yuhui Zheng “The Effect of Education on Health” 2011

[24] Michael Grossman “The demand for health, 30 years later: A very personal retro-
spective and prospective reflection” 2004

[25] Marten Palmea; Emilia Simeonova Does womens education affect breast cancer risk
and survival? Evidence from a population based social experiment in education 2014