With a multi-state model and data derived from a national 13-year longitudinal survey, this paper tries to explore the transition between health conditions of the Chinese elderly and, based on this exploration, discover inequalities in the life expectancy and the healthy life expectancy among elderly with different socioeconomic statuses. Compared with existing studies about health inequality in old age that generally deploy single indices (such as mortality or incidence rate of disease), this paper uses a comprehensive measuring index—the healthy life expectancy—to explore the health and health inequality of the elderly in China from a broad perspective. Furthermore, this paper includes a large number of elderly as its research sample, which helps us to study health inequality throughout the entirety of old age from a comprehensive perspective while also discovering the different influences of socioeconomic status on the health of the elderly at different ages. In addition, this paper fills the gap in previous research where the age effect and cohort effect were not made distinct through the exploration of the transitions in health inequality of the elderly at different ages and the transitions among different cohorts. Furthermore, unlike previous research that used Sullivan’s approach (Sullivan 1971), this paper adopts a multi-state model of continuous time points that can estimate and compare the health transition probabilities and the life expectancies of different subgroups (categorized by sex, age, place of residence, and level of education), in order to specifically reveal health inequality among the elderly and, to some extent, offset the estimation bias due to sample reduction.Footnote 7 This paper finds that there is no significant difference in the incidence rate of disability (the transition from health to disability) between the elderly in rural areas and the elderly in urban areas, yet the rural elderly have significantly higher rates of recovery (from disability to health) than their urban counterparts. These findings are inconsistent with what have been found in developed Western countries, where most research suggests that the incidence rate of disability of social groups with relatively low socioeconomic status is higher than that of social groups with high socioeconomic status (Jagger et al. 2007). Differences among social groups with respect to the rate of recovery have not been found in most research (Yong and Saito 2012). In China, the elderly in rural areas do not underperform in their incidence rate of disability but do outperform in their recovery rate, which may be related to the following factors. (1) A social selection mechanism based on health: as shown in this paper, the elderly in rural areas have higher transition rates from disability to death than their urban counterparts, which means that the surviving elderly in rural areas either have disabilities of low severity or better physical endowments that allow them to often outperform in the recovery from their disabilities. On the contrary, with good health services and living conditions, the elderly in urban areas have relatively low rates of mortality even though they suffer from serious disabilities. People with serious disabilities and poor physical endowments may thus survive in urban areas, though they usually underperform in the recovery from their disabilities. (2) The elderly in rural areas often live with poorly maintained facilities (such as washrooms, laundry facilities, cooking facilities, bathing facilities, and drinking water) that force them to take care of themselves with limited assistance from domestic facilities, not to mention that most old people in rural areas live in single-story houses and engage in many outdoor activities, all of which results in their strong ability to care for themselves throughout their daily lives. Even with similar states of health and functioning organs, the elderly in rural areas have better abilities to care for themselves in their daily lives and more optimistic attitudes in reporting on their ability to care for themselves than their counterparts living in urban areas. This may lead to the relatively low incidence rates for disability in the empirical study.
In addition, this paper shows that there is no significant gap within the incidence rate of disability among old people with different levels of education, though the disability recovery rate for the less educated elderly is higher than that of the well-educated, which is also inconsistent with research findings from developed Western countries. This is related to the factors discussed in the last paragraph. In a word, the inequality of the incidence rate of disability among social groups with different socioeconomic status, which is widely found in the Western world, has not yet emerged in China (Fuller et al. 2009; von dem Knesebeck et al. 2003). This is probably because the childhoods of China’s elderly, especially the very old, occurred during an historical period of long-lasting wars, and their adulthoods were spent during a period of planned economic systems and collectivisms after the founding of the People’s Republic of China and before the reform and opening up. Despite social stratification to some extent, most social groups have experienced relative equality in which socioeconomic backgrounds, such as education, have not played a key role in individual attainment of social resources or medical services, and they have had a relatively low influence on health. Consequently, the elderly with relatively high socioeconomic statuses have not accumulated advantages in health since the primes of their lives, and they have had no significantly lowered incidence rates for certain chronic disability-causing diseases compared to their counterparts with low socioeconomic status.
This paper demonstrates, however, that the inequality in mortality (including the transition from healthy to deceased and the transition from disabled to deceased) is significant. The elderly in rural areas have a higher risk of mortality than the elderly in urban areas, and the less educated elderly have a higher risk of mortality than those who are well-educated, which is consistent with most existing studies (Mackenbach et al. 2008). With respect to the inequality in mortality among old people with different socioeconomic statuses, we can explain this from several aspects. (1) With economic development and fundamental health care development, the major causes of mortality have already shifted from acute and epidemic diseases to chronic and mental disease. The incidence, treatment and recovery of the latter causes are significantly related to material resources, sanitary conditions, lifestyles, social relationships, and the knowledge of health possessed by individuals and social groups. (2) Due to their limited material resources as well as their relatively unhealthy lifestyles, the elderly with low socioeconomic statuses, who are often less educated or live in rural areas, have a relatively high incidence rate for chronic and lethal diseases (Howard et al. 2000; Steenland et al. 2002), especially for preventable lethal diseases (Masters et al. 2015). (3) Suffering from the same chronic and lethal diseases, or similar disabilities, the elderly with less education and who live in rural areas are impacted by the quantity and quality of accessible care services, medical technology, and services (Kapral et al. 2002). On the contrary, the elderly with high levels of education or who live in urban areas can make use of their access to medical services to slow down the progression of diseases and reduce the mortality risks of certain lethal diseases.
Furthermore, this paper examines the healthy life expectancy and its inequalities among the elderly at different places of residence and with different levels of education. It is found that the life expectancy of the elderly in rural areas is shorter than that of the elderly in urban areas, but the rural elderly have a longer healthy life expectancy, which is known as the “rural-urban paradox” and has been observed in some studies conducted in China. There are several possible causes of the “rural-urban paradox.” (1) According to the multi-state model in this paper, the span of the healthy life expectancy can be broken into two parts: first is the healthy life expectancy under original conditions of health multiplied by the probability of such conditionsFootnote 8; second is the healthy life expectancy after the transition from disabled to healthy multiplied by the probability of being originally disabled. (2) The rural elderly stay in a state of health longer than the urban elderly. The rural elderly have a higher probability of remaining healthy than their urban counterparts, which results in the rural elderly having a longer healthy life expectancy under original conditions of health than the elderly in urban areas. Moreover, the rural elderly outperform their urban counterparts in the transition from disability to health and thus have a longer healthy life expectancy after the transition to disability. These two factors lead to a longer total healthy life expectancy of the elderly in rural areas than that of the elderly in urban areas. (3) Due to their better recovery rate from disability and high mortality risk when disabled, the rural elderly have a shorter life expectancy than their urban counterparts after their transition from being healthy to disabled. They also have a shorter life expectancy when disabled and when their original condition is one of disability. In sum, the rural elderly live for relatively shorter durations in the condition of disability than their urban counterparts. On the contrary, in urban areas, good medical conditions and living environments protect the disabled elderly who would otherwise have relatively high mortality risks, and this prolongs their total life spans when disabled. (4) Since the rural-urban gap in the unhealthy or disabled life expectancy among old people is larger than the rural-urban gap in healthy life expectancy, the total life expectancy of the urban elderly is longer than that of the rural elderly, and the healthy life expectancy of the urban elderly is shorter than that of the rural elderly.
This paper also finds that the life expectancy and healthy life expectancy have a consistent trend among the elderly with different education levels: the less educated elderly have both a shorter life expectancy and a shorter healthy life expectancy compared to the well-educated elderly. But the healthy life expectancy of the less-educated elderly constitutes a greater proportion of the total life expectancy than that of the well-educated elderly, which is inconsistent with what is found in China (Wu and Xu 2011; Kaneda et al. 2005). The possible cause for this is that existing research is primarily based on data cross-sections at a single point of time or follow-up data for a short period of time, leading to biased conclusions. Several explanations can be formed to decode the findings of this paper. (1) When the original condition is health, the well-educated elderly have a longer healthy life expectancy compared to the less-educated elderly; when the original condition is one of disability, the well-educated elderly have a shorter life expectancy after the transition from disability to health compared to their less-educated counterparts. Well-educated people, however, still enjoy a longer total healthy life expectancy than less-educated people. (2) Similar to the rural-urban inequality in the unhealthy/disabled life expectancy, the well-educated elderly have a longer life expectancy after the transition from health to disability than the less-educated elderly due to their low recovery rate and low mortality risk under the condition of disability. When the original condition is disability, the well-educated elderly have a longer life expectancy in the condition of disability compared to the less-educated elderly, ultimately leading to their longer total life expectancy in the condition of disability. This reflects how the inequality in total life expectancy among old people with different levels of education is made up by the gap in healthy life expectancy and the gap in the unhealthy/disabled life expectancy. (3) Due to their relatively long healthy life expectancy and their unhealthy/disabled life expectancy, the well-educated elderly in general have a longer total life expectancy than their less-educated counterparts. The healthy life expectancy of the urban elderly occupies less of their total life expectancy than that of the rural elderly, and the healthy life expectancy of the well-educated elderly occupies a smaller proportion of their total life expectancy than that of less-educated people. This shows how the elderly with higher socioeconomic statuses are not experiencing the reduction in disabilities seen in Western societies (Crimmins and Saito 2001; Fries 2002). Instead, they are seeing increased disability.
Furthermore, this paper makes clear the age effect and the cohort effect. We discover that with respect to the life expectancy of the elderly, either rural-urban inequality or discrepancies among different education levels reduce along with the increase of age. The rural-urban inequality in the healthy life expectancy increases, however, at first and then decreases with age, while the inequality in the healthy life expectancy among the elderly with different levels of education consistently falls with age. In sum, the inequality in total life expectancy and the healthy life expectancy among the elderly with different socioeconomic statuses is decreasing with age, which is generally consistent with the research findings of the relevant studies (Huisman et al. 2003). It is worth noting that the discrepancy in the life expectancy among the elderly with different socioeconomic statuses does not disappear with age, though it does decrease as people get very old. This is also true when people reach the age of 95 or above. This indicates that both the incidence rate of disability and mortality increase significantly with age, and biological factors and individual physical endowments have greater influence on health than external socioeconomic factors, resulting in a tendency for the decreasing influence of socioeconomic factors. Moreover, with their aging and the considerable increase in mortality, the elderly with relatively low socioeconomic statuses can survive under the high rate of mortality and demonstrate their good physical endowments. On the contrary, the elderly with relatively high socioeconomic statuses can survive with the help of external socioeconomic conditions, even with poor physical endowments. Therefore, the physical endowments of the elderly with low socioeconomic statuses is probably better than that of the elderly with high socioeconomic statuses as they get very old, and thus the inequality in life expectancy and healthy life expectancy will decrease. Meanwhile, this paper finds that the elderly in rural areas and the less-educated elderly have a greater proportion of healthy life expectancy in their total life expectancy than their urban and well-educated counterparts, a tendency that increases with age. This finding also demonstrates that the urban elderly and well-educated elderly spend a greater proportion of their life expectancy in an unhealthy/disabled state than their rural and less-educated counterparts, a tendency that increases with age. As people get very old, good socioeconomic conditions can prolong life spans under the disabled condition. In other words, an increasing of disability has emerged in the group of elderly with high socioeconomic statuses, and this is even more severe in the group of the oldest senior citizens.
This paper also finds that the elderly in late cohorts have a longer life expectancy and a longer healthy life expectancy than those in early cohorts at the same age, which indicates that the people’s general health has improved with the development of society and the passing of time. All social groups have enjoyed this improvement no matter their different socioeconomic statuses, but they differ in degree. Generally speaking, the improvement of the urban elderly has been to a greater degree than that of the rural elderly, and the improvement of the well-educated elderly has been to a greater degree than that of the less-educated elderly. In other words, this paper reveals that the rural-urban inequality in life expectancy of the elderly increases with the advancing of the year of birth, and the rural-urban inequality in healthy life expectancy has decreased since the 1920s cohort. For life expectancy and healthy life expectancy, education inequality has enlarged with the advancing of the year of birth. These findings prove that health inequality among social groups with different socioeconomic statuses is increasing in the later cohorts (Lynch 2003). One of the major causes of this may be that social groups with different socioeconomic statuses are enjoying unequal health-related welfare from the development of society and the economy. Social groups with relatively high socioeconomic statuses can enjoy the health improvements brought by the development of society, medicine, and technology through easy access at an early stage. As society, medicine, and technology in China continue to progress, social groups with different socioeconomic statuses may undergo increasingly serious health inequalities in the future, and we should be aware of this and deal with the relevant countermeasures.
Finally, this paper has several limits. (1) This paper uses the basic activities of daily life as a health index to calculate the healthy life expectancy, also known as the active daily life expectancy. With a different health index, the calculated healthy life expectancy may be different. Whether the findings of this paper are applicable in describing the healthy life expectancy calculated by other health indices (such as the self-estimated healthy life expectancy, the disease-free life expectancy, or the no-cognitive-impairment life expectancy)—and whether the elderly with different socioeconomic statuses are different in terms of healthy life expectancy inequality—needs further discussion. (2) This paper uses the rural-urban index and education background as the measurement for socioeconomic status. Although previous studies agree that education better represents elderly socioeconomic status as opposed to occupation and income, it is worth further discussion whether health inequality among the elderly would be different if a different index, such as those based on financial assets and housing, were used to estimate socioeconomic status. (3) Although this paper distinguishes the age effect and cohort effect by examining health inequality among the elderly in different cohorts and at different ages, it only compares the conditions of four cohorts at several points of age due to the limited time scale of the longitudinal survey data. The difference among each cohort at different age points could be discussed if the longitudinal survey data with a longer time scale were available in the future.