摘要：Objectives. We examined the relationship between unemployment and mortality in Germany, a coordinated market economy, and the United States, a liberal market economy. Methods. We followed 2 working-age cohorts from the German Socio-economic Panel and the US Panel Study of Income Dynamics from 1984 to 2005. We defined unemployment as unemployed at the time of survey. We used discrete-time survival analysis, adjusting for potential confounders. Results. There was an unemployment–mortality association among Americans (relative risk [RR] = 2.4; 95% confidence interval [CI] = 1.7, 3.4), but not among Germans (RR = 1.4; 95% CI = 1.0, 2.0). In education-stratified models, there was an association among minimum-skilled (RR = 2.6; 95% CI = 1.4, 4.7) and medium-skilled (RR = 2.4; 95% CI = 1.5, 3.8) Americans, but not among minimum- and medium-skilled Germans. There was no association among high-skilled Americans, but an association among high-skilled Germans (RR = 3.0; 95% CI = 1.3, 7.0), although this was limited to those educated in East Germany. Minimum- and medium-skilled unemployed Americans had the highest absolute risks of dying. Conclusions. The higher risk of dying for minimum- and medium-skilled unemployed Americans, not found among Germans, suggests that the unemployment–mortality relationship may be mediated by the institutional and economic environment. The relationship between unemployment and mortality has been a well-studied phenomenon. Unemployment has been found to be associated with all-cause mortality 1–4 for both men 5–7 and women, 8,9 for older workers, 10–14 for cause-specific outcomes, 15,16 and after controls for health selection into unemployment. 17–20 Some studies have found that the relationship between unemployment and mortality is smaller during times of high unemployment than in times of low unemployment 21,22 ; studies of plant closure conducted during times of high unemployment have found a consistent relationship. 23,24 Unemployment has almost always been viewed as an individual-level risk factor on health within the context of a single country or economy. When context has been considered it has been to investigate whether the effect of unemployment on health is different during times or places with high unemployment compared with low unemployment. 22,25,26 Unemployment may influence health through material (e.g., loss of income) and psychosocial (e.g., loss of individual and social identity) pathways. These pathways are embedded in and influenced by societal and institutional context at every point, from determining who is unemployed (and who participates in the labor market), the meaning of unemployment, the material effect of unemployment, and the future employment consequences of unemployment. Recent scholarship in health inequalities has begun to characterize the structural and contextual features of a society that lead to better or worse population health outcomes. 27,28 This research has emphasized the importance of welfare-regime type as the principal independent variable in explaining variation in health inequalities among countries. Welfare-regime typologies classify countries according to how the state provides social and economic protection to its citizens. Although there are many welfare-regime typologies, 29 Esping-Andersen’s 30 typology that classifies countries into social democratic (universal provision), conservative (class-based provision), and liberal or residual (mean-tested provision) welfare-regime clusters is the most common. Few studies have examined whether the relationship between unemployment and health varies across welfare-regime type. Bambra and Eikemo found that the unemployed in liberal welfare regimes had the highest odds of reporting poorer self-reported health status for both unemployed men and women, but that high odds ratios were also found for unemployed men in conservative welfare regimes and women in social democratic welfare regimes. 31 Cooper et al. examined the relationship between unemployment and exit into poor health in 14 European countries, but did not find any relationship across welfare regimes. 32,33 Rodriguez examined whether the receipt of means-tested (i.e., welfare or social assistance) and unemployment benefits moderated the relationship between unemployment and self-assessed health in Germany (a conservative welfare regime), the United Kingdom, and the United States (2 liberal welfare regimes). 34 Regular unemployment benefits moderated the relationship between unemployment and health in all 3 countries compared with the unemployed in receipt of means-tested benefits. The unemployed not in receipt of any benefits in the United States also reported poorer self-assessed health. Hall and Soskice’s Varieties of Capitalism typology 35 provides a more relevant way of understanding how the institutional environment may affect the health of the unemployed because it is based, more directly than Esping-Andersen’s typology, on the conditions of employment and unemployment. Economies of high-income countries are grouped into coordinated market economies (CMEs) and liberal market economies (LMEs) that have different production specializations, similar economic growth and aggregate levels of wealth, but different economic and labor market institutions. Within CMEs and LMEs there is an interdependent relationship between the coordinating features of the market economy, the goods and services produced, the skills required by workers, and the potential future consequences of unemployment. The CMEs (e.g., Germany and Sweden) are characterized by collaboration among firms, trade unions, and other market actors and specialize in the production of goods and services that require a high degree of firm- or industry-specific skills and require workers that are technically or vocationally trained. High levels of employment protection (i.e., restrictions on terminating employees) and unemployment protection (i.e., the availability and level of unemployment benefits) safeguard the educational investment of workers, as once unemployed there may not be demand for their skills in other firms or industries. 36 In LMEs, by contrast, competitive market institutions predominate, including a flexible labor market with low levels of unemployment and employment protection. These economies specialize in goods and services that require general skills that are readily transferred across firms and industries. In accordance, the risk of unemployment and its effect on the health of the unemployed may vary across countries and within countries by skill level, depending on the protections provided to the unemployed and the opportunities for reemployment. Specifically, in LMEs the flexible labor market advantages those with high general skills (i.e., a university degree), whereas in CMEs the more coordinated labor market is structured to support workers with firm- and industry-specific vocational skills. 37 We examined whether the relationship between unemployment and mortality differs between Germany, a CME, and the United States, an LME, with 2 comparable working-age cohorts. We hypothesized that the higher levels of unemployment protection in Germany will mediate the effect of unemployment on mortality compared with the United States and that the gradient in the risk of unemployment on mortality by general educational status will be steeper in the United States compared with Germany.
