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Original Investigation
July 13, 2020

Comparison of Health Outcomes Among High- and Low-Income Adults Aged 55 to 64 Years in the US vs England

Author Affiliations
  • 1Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 3Department of Behavioural Science and Health, University College London, London, United Kingdom
  • 4Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor
  • 5Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
  • 6Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor
  • 7Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor
  • 8Institute of Epidemiology and Health Care, University College London, London, United Kingdom
JAMA Intern Med. 2020;180(9):1185-1193. doi:10.1001/jamainternmed.2020.2802
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.

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.

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