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Editor's Comment
Health Equity
August 5, 2020

Worse Health Outcomes for Adults With Low Incomes in the US vs England

Author Affiliations
  • 1Editor, JAMA Health Forum
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
JAMA Health Forum. 2020;1(8):e201004. doi:10.1001/jamahealthforum.2020.1004

A recent study1 in JAMA Internal Medicine has compared differences in health outcomes of middle-aged adults by income in the US and England. In this report, Choi and colleagues1 assessed survey and biomarker data from the US Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA). In these coordinated studies, nationally representative cohorts of adults 50 years and older were interviewed biennially using very similar surveys and biomarker measures.

Choi et al1 focused on adults aged 55 to 64 years, including 12 879 individuals in the US and 5693 individuals in England from 2008 through 2016. The research team assessed self-reported functional limitations; fair or poor health; depression; and 8 physician-diagnosed conditions, such as diabetes, heart problems, and chronic lung disease, that are fairly common in midlife. They also analyzed 3 directly measured intermediate health outcomes, including elevated blood pressure (>140/90 mm Hg), hemoglobin A1c (>6.5%), and C-reactive protein (>0.3 mg/dL [to convert to milligrams per liter, multiply by 10]). They further stratified these binational comparisons across deciles and quintiles of income to compare socioeconomic gradients in health.

Their study had 2 main findings. First, adjusted health outcomes were worse in the US than England for self-reported functional limitations, self-reported fair or poor health, the prevalence of all physician-diagnosed health conditions, and directly measured levels of hemoglobin A1c and C-reactive protein. Second, income-associated gradients in most health outcomes were significantly greater in the US than England, including functional limitations, fair or poor health, elevated blood pressure, and all physician-diagnosed conditions except cancer. Across both countries, the worst health outcomes were consistently evident among US adults in the lowest income quintile.

This study builds on an earlier JAMA study2 of middle-aged adults in the HRS and ELSA that used survey data from 2002 and also found greater income gradients in health outcomes in the US than England. Similarly, a JAMA Internal Medicine study3 of the HRS and ELSA from 2002 through 2012 showed that, in both countries, adults aged 54 to 64 years in the lowest quintile of wealth had substantially greater risks of disability and death, and these risks persisted through age 76 years. Other research4 in JAMA has shown wide geographic variations in life expectancy at age 40 years for adults with low incomes in the US, including 3-year to 5-year differences across states and metropolitan areas. When comparing individuals in the highest income groups, however, health outcomes are much more similar between the US and England1 and across areas of the US.4

The US and England share a common language and some cultural and economic similarities, but their health care and social welfare systems are notably different, and income inequality is much greater in the US. Policy makers and health care professionals in both countries have demonstrated growing interest in social determinants of health and racial/ethnic and socioeconomic differences in health outcomes, which are commonly called disparities in the US and health inequities in England and other countries.

Together with prior studies of socioeconomic disparities in health outcomes for middle-aged American adults, the recent study by Choi and colleagues1 helps to explain why the recent effects of coronavirus disease 2019 have been most severe among adults with low incomes in the US, particularly those who are Black or Hispanic.5 Rather than creating health disparities, coronavirus disease 2019 has rapidly unmasked preexisting disparities and made them starkly apparent for policy makers and the public. With the 2020 US election looming in 3 months, the challenge going forward will be to marshal the political will and votes needed to improve the socioeconomic and health opportunities of adults with low incomes through better wages, better employment opportunities, safer neighborhoods, and better access to affordable high-quality health care.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Choi  H, Steptoe  A, Heisler  M,  et al.  Comparison of health outcomes among high- and low-income adults aged 55 to 64 years in the US vs England.   JAMA Intern Med. Published online July 13, 2020. doi:10.1001/jamainternmed.2020.2802PubMedGoogle Scholar
Banks  J, Marmot  M, Oldfield  Z, Smith  JP.  Disease and disadvantage in the United States and in England.   JAMA. 2006;295(17):2037-2045. doi:10.1001/jama.295.17.2037PubMedGoogle ScholarCrossref
Makaroun  LK, Brown  RT, Diaz-Ramirez  LG,  et al.  Wealth-associated disparities in death and disability in the United States and England.   JAMA Intern Med. 2017;177(12):1745-1753. doi:10.1001/jamainternmed.2017.3903PubMedGoogle ScholarCrossref
Chetty  R, Stepner  M, Abraham  S,  et al.  The association between income and life expectancy in the United States, 2001-2014.   JAMA. 2016;315(16):1750-1766. doi:10.1001/jama.2016.4226PubMedGoogle ScholarCrossref
Yancy  CW.  COVID-19 and African Americans.   JAMA. 2020;323(19):1891-1892. doi:10.1001/jama.2020.6548PubMedGoogle ScholarCrossref
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