The title might be an appropriate giveaway, but in this exceptional book Julia Lynch shows how health inequalities need to be in conversation with the broader literature on income and wealth inequality. Social scientists studying income and wealth inequality may say health inequalities are just one of many outcomes of income and wealth inequalities and therefore are a downstream effect. They are right, of course, but the implication of this view is that policies pertaining to income and wealth are the dominant upstream policies and therefore should remain the central focus of work on inequality. There are two problems with this view. First, as Lynch points out—and as health policy scholars have known for decades—there is a reciprocal relationship between health and income/wealth, making it impossible to separate the two concerns. Health status is fundamental; after all, people are born with health endowments that shape numerous opportunities throughout the life course. Moreover, income and wealth inequalities get “under the skin,” affecting biology in ways that have intergenerational effects (Villarosa 2022). Second, and this is central to Lynch's book, policy actors do not view health inequalities as second-order concerns. Especially in Europe, which is the focus of her book, policy actors elevated health inequalities to central positions in their political platforms. Indeed, a central question that Lynch examines is: what happens when political actors frame social inequality in terms of health inequalities? Her answer is complex but well worth the time to work through it.
She argues that neoliberalism in praxis explains both why health inequality is elevated in framing social inequality and why policy actors reject redistribution tools to address income/wealth inequality, which are the upstream social determinants of health. Because targeted distribution of health care for those in greater need (or ill health) is the proffered solution to health inequity, it fits well with neoliberal ideology by making providers the central node in the distribution and providing government funding for provider-based distributions. This central finding emerges out of a puzzle that Lynch discovered early in her research: “the presence of variation in the framing of health inequalities [across countries], but the lack of meaningful variation in the policies that emerged out of these different frames” (19, Kindle edition). Understanding this puzzle became the central focus of her book. As such, her primary cases were England, France, and Finland, because they were the most different on the dimensions that one would think would matter most for producing different health equity policies: the timing of adopting and the salience of health inequality frames, and the type of health system and welfare state system. What this “most different systems” methodological approach allows Lynch to unravel is the dominance of neoliberalism across very different systems—both different welfare regimes and different health systems.
Lynch shows in her careful analysis of these three countries how the hegemony of neoliberal ideas is not complete. While it serves to push the traditional tools of economic management and redistribution off limits, this political infeasibility does not uniformly extend to other forms of health inequality. The reason for this is that center-left politicians across very different systems uniformly believed their electorates were less interested in income and wealth redistribution, such as much more progressive taxation schemes and/or more direct income transfers to poor and low-income people. Instead, they believed their electorates supported neoliberal ideas that distributed in-kind benefits that often incorporate the private sector in policy designs. This is why, Lynch argues, the center-left took up the issue of health inequalities: they could rally their electorate around more liberal policies in the health domain while still supporting neoliberalism in the economic domain.
This finding illustrates why it is essential to bring these two scholarly disciplines together: social scientists focused on income/wealth inequality and public health researchers focused on health inequalities. She situates these literatures in chapter 2 but brings them together conceptually throughout the remainder of the book.
Chapter 3 lays the foundation to understand how the international community fostered by World Health Organization (WHO) Europe emphasized the importance of health inequalities and the impact of social determinants in seminal documents that created a consensus frame. This sets the stage, Lynch argues, for how policy actors in England, France, and Finland framed health inequalities as a substitute for frames that elevated income/wealth inequality and ironically allowed for these countries to respond to their post-1980 welfare regimes with a hegemonic neoliberal policy paradigm despite WHO Europe's insistence that to focus on health inequalities one must center the social determinants of health (i.e., income/wealth inequalities). In chapters 4–6, she details this persistent pattern across these three countries: how the center-left created self-imposed taboos against using income redistributive policy solutions and introduced health inequalities with targeted health care distributions as a substitute for discussions of income/wealth inequalities.
Of course, it will not come as a surprise to those who know the importance of social determinants for reducing health inequalities that this substitution strategy failed. Lynch details this failure in chapter 7. Although this book focuses on three countries, the power of the “most different systems” approach is to suggest that this pattern has a much broader reach. One can certainly see similarities in approach and lessons for the United States. For example, as health equity has become a growing focal point among the center-left in the United States, at least since the 2010 passage of the Affordable Care Act, we find a similar frame that avoids any real discussion of income or wealth redistribution and a much more narrow focus on using the Medicaid program to target health and social services for persons in disadvantaged communities.
Lynch ends the book with unraveling another extremely important puzzle: why center-left policy actors self-censor their policy frames in ways that are so favorable to neoliberalism. Part of the explanation is the hope that medicalizing inequality would offer a solution to more intractable systemic problems. Lynch's last chapter again offers important lessons for the United States. Another common approach to health inequalities in the United States is to emphasize the importance of cross-sector collaboration, which in practice has often meant shifting policy decision-making over to health actors. She shows how this “health in all policies” approach in all three countries proved to be disappointing and largely ineffective, and the medicalizing of social inequality served to emphasize an individual-level response to inequality.
Regimes of Inequality is essential reading for anyone wanting a deeper understanding of health inequalities and how this is importantly intertwined with the politics of income/wealth inequality. It should be included on health policy, health politics, and comparative health systems syllabi. Lynch reminds us that there are no shortcuts to truly dealing with inequality. It demands a focus on societal structures and redistribution. Most importantly, Lynch makes clear that we do not have to (nor should we) accept these social and economic inequalities as foreground conclusions. Political and policy choices matter.
