HwaJung Choi1,2, Andrew Steptoe3, Michele Heisler1,2,4, Philippa Clarke2,5,6, Robert F Schoeni2,6,7, Stephen Jivraj8, Tsai-Chin Cho1, Kenneth M Langa1,2,4,6. 1. Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor. 2. Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor. 3. Department of Behavioural Science and Health, University College London, London, United Kingdom. 4. Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor. 5. Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor. 6. Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor. 7. Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor. 8. Institute of Epidemiology and Health Care, University College London, London, United Kingdom.
Abstract
Importance: Socioeconomic differences in life expectancy, health, and disability have been found in European countries as well as in the US. Identifying the extent and pattern of health disparities, both within and across the US and England, may be important for informing public health and public policy aimed at reducing these disparities. Objective: To compare the health of US adults aged 55 to 64 years with the health of their peers in England across the high and low ranges of income in each country. Design, Setting, and Participants: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) for 2008-2016, a pooled cross-sectional analysis of comparably measured health outcomes, with adjustment for demographic characteristics and socioeconomic status, was conducted. The analysis sample included community-dwelling adults aged 55 to 64 years from the HRS and ELSA, resulting in 46 887 person-years of observations. Data analysis was conducted from September 17, 2019, to May 12, 2020. Exposures: Residence in the US or England and yearly income. Main Outcomes and Measures: Sixteen health outcomes were compared, including 5 self-assessed outcomes, 3 directly measured outcomes, and 8 self-reported physician-diagnosed health conditions. Results: This cross-sectional study included 12 879 individuals and 31 928 person-years from HRS (mean [SD] age, 59.2 [2.8] years; 51.9% women) and 5693 individuals and 14 959 person-years from ELSA (mean [SD] age, 59.3 [2.9] years; 51.0% women). After adjusting for individual-level demographic characteristics and socioeconomic status, a substantial health gap between lower-income and higher-income adults was found in both countries, but the health gap between the bottom 20% and the top 20% of the income distribution was significantly greater in the US than England on 13 of 16 measures. The adjusted US-England difference in the prevalence gap between the bottom 20% and the top 20% ranged from 3.6 percentage points (95% CI, 2.0-5.2 percentage points) in stroke to 9.7 percentage points (95% CI, 5.4-13.9 percentage points) for functional limitation. Among individuals in the lowest income group in each country, those in the US group vs the England group had significantly worse outcomes on many health measures (10 of 16 outcomes in the bottom income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the bottom income decile ranged from 7.6% (95% CI, 6.0%-9.3%) vs 3.8% (95% CI, 2.6%-4.9%) for stroke to 75.7% (95% CI, 72.7%-78.8%) vs 59.5% (95% CI, 56.3%-62.7%) for functional limitation. Among individuals in the highest income group, those in the US group vs England group had worse outcomes on fewer health measures (4 of 16 outcomes in the top income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the top income decile ranged from 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for hypertension to 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for arthritis. Conclusions and Relevance: For most health outcomes examined in this cross-sectional study, the health gap between adults with low vs high income appeared to be larger in the US than in England, and the health disadvantages in the US compared with England are apparently more pronounced among individuals with low income. Public policy and public health interventions aimed at improving the health of adults with lower income should be a priority in the US.
Importance: Socioeconomic differences in life expectancy, health, and disability have been found in European countries as well as in the US. Identifying the extent and pattern of health disparities, both within and across the US and England, may be important for informing public health and public policy aimed at reducing these disparities. Objective: To compare the health of US adults aged 55 to 64 years with the health of their peers in England across the high and low ranges of income in each country. Design, Setting, and Participants: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) for 2008-2016, a pooled cross-sectional analysis of comparably measured health outcomes, with adjustment for demographic characteristics and socioeconomic status, was conducted. The analysis sample included community-dwelling adults aged 55 to 64 years from the HRS and ELSA, resulting in 46 887 person-years of observations. Data analysis was conducted from September 17, 2019, to May 12, 2020. Exposures: Residence in the US or England and yearly income. Main Outcomes and Measures: Sixteen health outcomes were compared, including 5 self-assessed outcomes, 3 directly measured outcomes, and 8 self-reported physician-diagnosed health conditions. Results: This cross-sectional study included 12 879 individuals and 31 928 person-years from HRS (mean [SD] age, 59.2 [2.8] years; 51.9% women) and 5693 individuals and 14 959 person-years from ELSA (mean [SD] age, 59.3 [2.9] years; 51.0% women). After adjusting for individual-level demographic characteristics and socioeconomic status, a substantial health gap between lower-income and higher-income adults was found in both countries, but the health gap between the bottom 20% and the top 20% of the income distribution was significantly greater in the US than England on 13 of 16 measures. The adjusted US-England difference in the prevalence gap between the bottom 20% and the top 20% ranged from 3.6 percentage points (95% CI, 2.0-5.2 percentage points) in stroke to 9.7 percentage points (95% CI, 5.4-13.9 percentage points) for functional limitation. Among individuals in the lowest income group in each country, those in the US group vs the England group had significantly worse outcomes on many health measures (10 of 16 outcomes in the bottom income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the bottom income decile ranged from 7.6% (95% CI, 6.0%-9.3%) vs 3.8% (95% CI, 2.6%-4.9%) for stroke to 75.7% (95% CI, 72.7%-78.8%) vs 59.5% (95% CI, 56.3%-62.7%) for functional limitation. Among individuals in the highest income group, those in the US group vs England group had worse outcomes on fewer health measures (4 of 16 outcomes in the top income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the top income decile ranged from 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for hypertension to 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for arthritis. Conclusions and Relevance: For most health outcomes examined in this cross-sectional study, the health gap between adults with low vs high income appeared to be larger in the US than in England, and the health disadvantages in the US compared with England are apparently more pronounced among individuals with low income. Public policy and public health interventions aimed at improving the health of adults with lower income should be a priority in the US.
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