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High- and low-income health gap in U.S. compared to England

July 15, 2020

Topics: Quote of the Day

By HwaJung Choi, Ph.D.; Andrew Steptoe, D.Sc.; Michele Heisler, M.D., M.P.H.; Philippa Clarke, Ph.D.; Robert F. Schoeni, Ph.D.; Stephen Jivraj, Ph.D.; Tsai-Chin Cho, M.Sc.; Kenneth M. Langa, M.D., Ph.D.
JAMA Internal Medicine, July 13, 2020

Key Points

Question: What is the difference in health status between high- and low-income individuals in the US vs England?

Findings: In this cross-sectional study including 18 572 persons (46 887 person-years of observations), the health gap between the bottom 20% and top 20% of income distribution was significantly greater for US adults aged 55 to 64 years than their English peers on 13 of 16 health measures. In addition, for most measures, the health of US adults appeared to be poorer than that of their peers in England, especially those from the lower end of the income distribution.

Meaning: The findings of this study suggest that the income-health gradient is greater among US middle-aged adults than among their peers in England, with poor health especially pronounced among those with lower income in the US.

From the Introduction

This study compared the health of US adults aged 55 to 64 years with the health of their peers in England. The US and England have a relatively similar culture, language, and economic system, yet have substantially different health care and social welfare systems. The US provides limited public health insurance for those younger than 65 years, but England provides publicly funded health care free at the time of service for all individuals under the National Health Service. About 17% of US adults aged 55 to 64 years had only public health insurance coverage, and 13% had no health insurance coverage in 2012-2013. The greater level of income inequality with limited public safety net in the US compared with England raises the question of whether those with low income in the US are at greater risk for poor health outcomes than low-income adults in England.

From the Discussion

Using data on adults aged 55 to 64 years from comparable nationally representative surveys of the US and England, this study provides evidence on disparities in health across income groups in the US vs England. Analyses of 16 health outcomes found substantial income differences in each country and for all outcomes except cancer in both countries and measured high blood pressure in England. Moreover, the disparity in health between low-income and high-income adults was significantly greater in US adults for 6 of the 8 self-assessed or directly measured outcomes, and 7 of the 8 self-reported physician diagnosis outcomes.

Cross-country differences in health were in favor of England for all health outcomes except ADL limitations, depression, and measured blood pressure, which were not significantly different between countries. The US and England disparities were pronounced among lower-income adults.

From the Conclusions

The findings of this study suggest that the gap in health between lower-income vs higher-income adults is substantial and significantly larger in the US than England for most health outcomes that we examined. In addition, lower-income adults in the US appear to have poorer health compared with lower-income adults in England.



By Don McCanne, M.D.

The United States and England have similar cultures but different health care financing systems. This study looked at health care outcomes in both countries in the top and bottom income quintiles of those 55 to 64 – the last decade before most U.S. citizens become eligible for our government Medicare program.

The health gap between the top and bottom quintiles is significantly greater in the United States than it is in England. Further, the health of U.S. adults is poorer than their peers in England, especially for those with lower incomes.

Also income inequality is greater in the United States than it is in England. Everyone in England receives care free at the time of service through their national health service, whereas the health care financing system in the United States is fragmented with a limited public safety net.

What is more remarkable is that England has better outcomes even though its per capita health expenditures are half that of the United States.

We have the money, and we’re already spending it – $4 trillion this year. But we sure could do a lot better on how we spend it. A single payer improved Medicare for All would work just fine. And about that income inequality, we could take a major step forward by using more equitable tax policies to fund a $4 trillion universal risk pool.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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