Can patient self-management explain the health gradient? Goldman and Smith's “Can patient self-management help explain the SES health gradient?” (2002) revisited

In their much-cited paper, “Can patient self-management help explain the SES health gradient?” Goldman and Smith (2002) use samples of diabetic and HIV+ patients in the United States to conclude that disease self-management is an important explanation for the much-documented positive gradient in education and health outcomes. In this paper, I revisit their analysis and point to some fundamental difficulties in interpreting their results as conclusive evidence in favor of self-management. I also argue that for individuals for whom self-management might be expected to matter -i.e. populations of patients managing complex conditions - economic factors such as resource availability and insurance access might be a more important mechanism behind the gradient than medical compliance. The impact of self-management, though it might matter, is likely to be small.