Book reviews for The Journal of Pension Economics and Finance reflect reviewers' own views and in no way represent the views of the institution(s) with which they are affiliated.
This book is a compendium of research articles focused on documenting the factors affecting the U.S. decline in disability, with a larger goal of accurately forecasting the future path of health, disability, and costs associated with an aging population. The research presented in the volume is part of an ongoing project at the National Bureau of Economic Research directed at understanding disability. The contributors are leaders in their respective fields and the articles are uniformly good – well written, convincing, and designed to leave readers current on each of the covered topics. Notably, the collected nature of the book does not interrupt the flow from topic to topic, making this book an interesting read from cover to cover.
The volume evaluates the factors that have contributed to the trend of declining disability, and asks to what extent these factors will continue to put downward pressure on disability rates in the future. Answers to these questions are critical to evaluating the quality of later life and the value of increased life expectancy; to estimating and controlling costs associated with an aging population; to understanding the growth in work disability; and to allocating future health investments efficiently. To provide a context for understanding the individual articles, the editors David Cutler and David Wise, along with Richard Woodbury, lay out a structural framework for studying disability in the volume's introduction. Their framework makes clear that disability is not a single well-defined concept, succinctly measured by health or functional limitations. Rather, it is a complex process, with multiple factors influencing it, frequently in offsetting ways. In their model, the study of disability includes exploration of its (1) causes, including health behavior, medical technologies, demographics, education, socioeconomic status, as well as the interactions among them; (2) characteristics, including chronic conditions, medical management, core functioning, assistive systems and social environment, and functioning with supports; and (3) consequences, including disability insurance, work and productivity, health care costs and caregiving costs, and government finances. While the exact classification of the items in the schematic will spur debate, (e.g., are demographic variables ultimately a cause or just a marker for underlying causes, is disability insurance potentially a cause and a consequence), the idea that disability is complex and that its study requires a multidimensional model of a process is one of the critical points of the book.
The remainder of the book is divided into five sections meant to provide information about the component parts of the framework. Given the number of articles in each section, the comments here are general to the topic areas, rather than focused on the merits of individual articles. The first section, Disability Trends, focuses on factors driving the decline in the flow of health conditions that potentially lead to disability. Findings suggest that the decline in disability over the past century is related to improvements in health associated with medical advances, public health initiatives (e.g., vaccinations, cleaning of the milk supply), improved health behaviors, improved economic conditions (e.g., less physically demanding jobs), and higher educational attainment. Importantly, the benefits of these improvements appear to have gone disproportionately to higher socioeconomic groups, increasing the disparities in health and disability across the population. In the next section, Pathways to Disability, the authors explore how health conditions develop into disabilities. The results show that while health and disability are not synonymous, they are linked, and the linkages appear stronger for those with lower socioeconomic status and lower educational attainment. Targeted medical and nonmedical interventions are important, as the population with disabilities is heterogeneous. The third section on Medical Advances and Disability, considers how improvements in medical technology affect health and disability and whether those improvements will translate into cost savings. While there is compelling evidence that interventions positively affect health and disability, cost savings may prove more elusive. Spending on medical care is rising faster for those without functional limitations than for those with functional limitations, potentially offsetting the cost savings from reduced disability.
The final two sections focus on the consequences of disability. The section on Work Disability looks at how health and functional limitations affect work disability and disability insurance programs. Although each chapter adds a unique dimension to the topic, the common theme among them is that work disability is affected both by underlying health and by the cultural, social, and policy environment individuals find themselves in. Defining social expectations, deploying appropriate health related interventions, and ensuring that disability insurance programs have appropriate incentives influence the rate at which health conditions become work disabilities. The final section, Assistive Technology and Caregiving, looks at how people and their families function with physiological limitations. A key point of this section is that the negative spillovers of disease and disability on family and friends should be taken into account when computing the welfare gains for increased health among the population.
This book is a balanced and interesting treatment of a wide range of issues important to discussions of the aging population. Its only shortcoming is that it is too technical to be accessible reading for the policy makers most likely to be in charge of implementing the ideas summarized in the articles. While this clearly was out of the scope of this book, adding such a goal to the future agenda seems warranted given the importance of the findings presented in the book.
