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

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.

This cross-sectional study compares health care outcomes in middle-aged adults in the US vs England by income status.

Introduction

The US spends more on health care than any other country, but health and life expectancy of US adults have been decreasing compared with many other high-income countries.¹ Life expectancy in the US has remained relatively stable in recent years,^1,2,3 although some evidence that mortality rates among middle-aged US adults have increased has been reported.^4,5 The US health disadvantage is found not only in life expectancy but also in self-reported health,⁶ biomarkers for disease,⁷ and many specific causes of death,^6,8,9,10 which is persistent and substantial, even after controlling for individual risk factors and health care system factors.^1,7,11

Socioeconomic differences in life expectancy,¹² health,¹³ and disability¹⁴ have been found in European countries as well as in the US. However, compared with many European countries, the US has higher income inequality^15,16,17 and has a relatively limited government safety net including public health care coverage.^7,18 We believe that the relative health disadvantage of the US compared with many European countries would be especially greater among people with low income than people with higher income.

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.^7,18 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 2012-2013.¹⁹ The greater level of income inequality¹⁶ 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.

To our knowledge, few studies have examined health differences between the US and England by socioeconomic groups. Zaninotto et al¹⁴assessed socioeconomic differences in disability-free life expectancy in England and the US, examining it by occupation, wealth, and educational level. Lee and Smith²⁰ examined the social gradient in health across high-income countries, including the US and England, focusing on educational level and wealth. Makaroun et al²¹ compared mortality and disability among adults in different wealth quintiles in the US and England. However, these studies did not examine US-England health differences by income group. While educational level, occupation, and wealth are important, income may have an independent association with health and health care access, especially for people with limited public health care coverage. Banks et al⁷ examined US-England health differences among adults aged 55 to 64 years by income tertile in 2002 and found worse health in the US regardless of income group. However, to our knowledge, little evidence exists on whether these differences by income between the US and England have persisted in recent decades. Since 2002, the baby boom generation (born between 1946-1964) in the US has entered the age 55- to 64-year cohort with worse health than earlier generations,²² which has important implications for the health and health care needs of US adults. In addition, using more granular income groupings than tertiles may be important because income gradients in health are typically steeper at lower levels of income.²³

To address this gap in evidence, we examined differences between the US and England in health among adults aged 55 to 64 years by using more recent years of data and more fine-grained income groups than in prior studies. We examined 16 health outcomes measured in comparable nationally representative data from the US and England from 2008 to 2016.

Methods

Data Sources and Sample

The Health and Retirement Study (HRS) is a longitudinal biennial survey of approximately 20 000 Americans older than 50 years that started in 1992. The HRS collects extensive health information as well as sociodemographic characteristics.²⁴ The HRS was approved by the University of Michigan Institutional Review Board. The English Longitudinal Study of Ageing (ELSA) is a biennial longitudinal household survey of English adults aged 50 years or older that began data collection in 2002 including detailed health and sociodemographic measures. The ELSA was developed with a goal of using methods and survey questions that are comparable to the HRS to facilitate cross-national comparisons.²⁵ Ethical approval for all the ELSA waves was granted by the National Health Service Research Ethics Committees under the National Research and Ethics Service. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.

Our study sample included community-dwelling adults aged 55 to 64 years from both the HRS and ELSA over the period 2008-2016. This age group was chosen because 55 years is the youngest age to be nationally representative for all years and 64 years is the oldest age before eligibility for the Medicare program in the US. There were 12 879 persons and 31 928 person-year observations from the HRS and 5693 persons and 14 959 person-year observations from the ELSA. The sample size and sample period varied depending on the health outcomes examined because some health measures were not available for the entire study period.

Measures

We examined 16 harmonized measures for the HRS and ELSA.²⁶ Five measures of self-assessed health outcomes were any functional limitation (climbing 1 flight of stairs; climbing several flights of stairs; getting up from a chair; picking up a dime; reaching or extending arms upward; pushing or pulling large objects; sitting for 2 hours; lifting or carrying 4.5 kg; and stooping, kneeling, or crouching), difficulty with any instrumental activity of daily living (IADL) (using the telephone, managing money, taking medication, shopping, and preparing meals), difficulty with any activity of daily living (ADL) (walking across the room, dressing, bathing, eating, getting in or out of bed, and using the toilet), fair or poor self-rated general health, and depressive symptoms according to the 8-item Center for Epidemiologic Studies Depression Scale (CES-D8).²⁷ Three directly measured health outcomes were blood pressure (elevated level defined as ≥140 mm Hg systolic or ≥90 mm Hg diastolic),²⁸ hemoglobin A_1c (HbA_1c) level, (elevated level defined as >6.5% [to convert to proportion of total hemoglobin, multiply by 0.01]), and C-reactive protein (CRP) level (elevated level defined as >0.3 mg/dL [to convert to milligrams per liter, multiply by 10]). Eight measures of self-reported physician-diagnosed health conditions were hypertension, arthritis, diabetes, heart problems, cancer, stroke, chronic lung disease, and emotional or psychiatric problem. There were fewer than 4.8% missing values in health outcomes in the HRS and fewer than 6.3% in the ELSA.

Demographic measures included age, sex, foreign-born status (outside the US for HRS; outside the UK for ELSA), race (white vs other), household size (number of people living in the household), and marital status (partnered, separated/divorced, widowed, and never married). Educational level groups included a 3-tiered harmonized scale.²⁹ To adjust for rank in the income distribution, we used income decile within each country, based on household income. For analyses by income groups, we used the income quintiles, deciles, and percentiles, defined within each country, survey year, and age, with the adjustment for household size. There were fewer than 0.5% missing values for all covariates except educational level (6.4%) and income (2.4%) in the ELSA.

Statistical Analysis

Data analysis was performed from September 17, 2019, to May 12, 2020. We conducted pooled cross-sectional analyses to compare health differences and their variation by income group (quintile, decile, and percentile). We used multivariable logistic regressions to adjust for demographic and socioeconomic characteristics and estimated the adjusted risk ratios (ARRs) of health problems for the HRS sample vs ELSA sample by evaluating estimated risks at the grand mean values of covariates.³⁰

To estimate the adjusted prevalence of health problems by income in each country, we included as explanatory variables the indicator variables for each country-specific income decile, the indicator for the HRS sample, an interaction between the indicator variables for each income decile and an indicator for the HRS sample, and demographic covariates. The adjusted prevalence within each income decile for each survey (HRS and ELSA) was calculated. We also calculated the health difference between the bottom 20% and the top 20% in each country as well as between the countries to assess whether the health gap by income varied between the US and England.

Auxiliary and sensitivity analyses were conducted. First, we summarized sample characteristics for the HRS and ELSA. Second, we estimated the unadjusted prevalence of health problems in each country and unadjusted risk ratios of health problems for the US vs England. Third, to examine the income distribution, we collected data on median income by income decile for HRS and ELSA. Fourth, to examine more detailed income patterns, we calculated health outcomes for each income percentile (1 for the lowest and 100 for the highest income level) defined within each country by using a kernel-weighted local polynomial regression.³¹ Fifth, we reassessed health differences after restricting the sample to non-Hispanic white individuals from the HRS sample. Sixth, we adjusted for smoking and body mass index to examine whether these variables were associated with the results. Seventh, we used a multiple imputation technique to impute missing values in covariates using chained equations with 10 replications. Two-tailed unpaired P values were determined from a t test of whether the estimate of difference in the adjusted prevalence was significantly different from 0. Findings were considered significant if 95% CIs were not overlapped and the P value was less than .05.

All analyses were conducted using Stata, version 15 (StataCorp). Standard errors and population weight were adjusted using the complex survey design from the HRS and ELSA.

Results

This cross-sectional study included 12 879 individuals and 31 928 person-years from HRS (mean age, 59.2 years; 51.9% women) and 5693 individuals and 14 959 person-years from ELSA (mean age, 59.3 years; 51.0% women) (eTable 1 in the Supplement). The proportion of foreign-born adults (11.2% in HRS and 12.2% in ELSA) was comparable between the US and England, but the proportion of white individuals was lower in the HRS sample (79.9% vs 93.8%; P < .001). The HRS sample was composed of more single-person households (19.0% vs 15.6%; P < .001) and large households with 5 or more persons (6.2% vs 3.0%; P < .001), as well as those without a spouse (29.6% vs 23.7%; P < .001). The proportion of adults with a high level of education was greater in the US compared with England (31.9% vs 21.9%; P < .001), and US adults were more likely to have never smoked (45.1% vs 39.1%; P < .001) and to be obese (38.5% vs 34.4%; P < .001).

As depicted in Figure 1, adults in the US compared with England were significantly more likely to report a functional limitation (ARR, 1.46; 95% CI, 1.40-1.52), IADL limitation (ARR, 1.46; 95% CI, 1.27-1.66), and fair or poor self-rated general health (ARR, 1.22; 95% CI, 1.13-1.32). The adjusted prevalence of an ADL limitation and depression was comparable between the US and England. US adults had a significantly greater adjusted prevalence of a high HbA_1c level (ARR, 1.48; 95% CI, 1.23-1.79) and a high CRP level (ARR, 1.17; 95% CI, 1.04-1.30). The adjusted prevalence of directly measured high blood pressure was comparable, while self-reported physician-diagnosed hypertension was significantly higher in the US than England (ARR, 1.39; 95% CI, 1.32-1.47). All physician-diagnosed health conditions were more prevalent among US adults, with the ARR ranging from 1.25 (95% CI, 1.14-1.35) for heart problems to 2.17 (95% CI, 1.81-2.54) for chronic lung disease.

Figure 1. Adjusted Risk Ratios (ARRs) for US-England Health Differences at Ages 55 to 64 Years for 2008-2016.

Adjustment factors included survey year, age, sex, race, foreign-born status (outside the US for HRS; outside the UK for ELSA), household size, marital status, educational level in International Standard Classification of Education categories, and household income in decile. Estimates were calculated holding all adjustment factors at their grand mean values (ie, constant across countries). ADL indicates activities of daily living; CES-D8, 8-item Center for Epidemiologic Studies Depression Scale; CRP, C-reactive protein; HbA_1c, hemoglobin A_1c; and IADL, instrumental ADL.

The unadjusted prevalence and risk ratios of health problems in the US vs England are reported in eTable 2 in the Supplement. The risk ratios of 12 of 16 health problems were higher in the US than England ranging from 1.14 (95% CI, 1.04-1.24) for high inflammation to 2.22 (95% CI, 1.86-2.57) for stroke. The overall findings were robust to additional sample restrictions including only non-Hispanic white individuals, additional adjustments for smoking and body mass index, and use of imputed data (eFigure 1, eFigure 2, and eFigure 3 in the Supplement).

Variation in Health by Income in the US and England

The unadjusted prevalence of each of the 16 health outcomes by income percentile suggested a strong income-health gradient for most outcomes in each country (eFigure 4 in the Supplement). For example, the prevalence of functional limitation in the 10th percentile vs 90th percentile was 78.5% vs 39.6% for the US and 57.8% vs 30.9% for England. The prevalence of high inflammation in the 10th percentile vs 90th percentile was 42.6% vs 25.9% for the US and 33.6% vs 24.8% for England. The prevalence of diabetes in the 10th percentile vs 90th percentile was 29% vs 11.7% for the US and 14.5% vs 6.0% for England. Furthermore, these figures suggest that, among health outcomes that differ between countries, the gap is never larger and often smaller at the top than the bottom of the income distribution.

Median household income of adults aged 55 to 64 years was greater in the US than England for all deciles except for the bottom decile (eTable 3 in the Supplement). The median after-tax household income (US dollars) was $3650 in the US vs $5286 in England at the bottom decile in each country during 2008 to 2014. In contrast, the median after-tax household income in the US was more than twice the value in England at the top decile in 2012 ($143 679 vs $70 712), implying higher income inequality in the US (ratio of median within the top vs bottom decile was 39 in the US and 13 in England).

As presented in the Table, the gap between the bottom 20% and the top 20% on self-assessed health outcomes was substantial for both countries, ranging from a 22 percentage point difference (IADL limitation) to a 38 percentage point difference (fair or poor health) in the US and from a 16 percentage point difference (IADL limitation) to a 33 percentage point difference (fair or poor health) in England. This health gap by income (bottom 20% minus top 20%) was significantly greater in the US than England on functional limitation (US-England difference in the gap was 9.7 percentage points; 95% CI, 5.4-13.9 percentage points), IADL limitation (US-England difference in the gap was 5.3 percentage points; 95% CI, 2.2-8.4 percentage points), ADL limitation (US-England difference in the gap was 4.8 percentage points; 95% CI, 1.3-8.3 percentage points), and fair or poor health (US-England difference in the gap was 4.9 percentage points; 95% CI, 0.7-9.1 percentage points) (Table).

Table. Health Difference Between the Bottom 20% and Top 20% of Income Distribution in the US and England at Ages 55 to 64 Years for 2008-2016^a.

Variable	Bottom 20% minus top 20% in HRS		Bottom 20% minus top 20% in ELSA		HRS minus ELSA in the gap (bottom 20% minus top 20%)
	Percentage point (95% CI)	P value	Percentage point (95% CI)	P value	Percentage point (95% CI)	P value
Self-assessed health outcomes
Functional limitation	35.8 (32.5 to 39.0)	<.001	26.1 (23.0 to 29.2)	<.001	9.7 (5.4 to 13.9)	<.001
IADL limitation	21.5 (18.6 to 24.4)	<.001	16.2 (14.3 to 18.2)	<.001	5.3 (2.2 to 8.4)	<.001
ADL limitation	22.5 (19.4 to 25.5)	<.001	17.6 (15.5 to 19.8)	<.001	4.8 (1.3 to 8.3)	.007
Fair or poor health	37.9 (34.1 to 41.7)	<.001	33.0 (30.3 to 35.7)	<.001	4.9 (0.7 to 9.1)	.02
Depression (CES-D8 score ≥3)	23.9 (21.1 to 26.7)	<.001	26.3 (23.6 to 29.0)	<.001	–2.4 (–6.1 to 1.3)	.20
Directly measured health outcomes
High BP (systolic ≥140 or diastolic ≥90 mm Hg)	6.6 (0.3 to 13.0)	.04	–1.6 (–6.2 to 3.0)	.50	8.2 (1.1 to 15.3)	.02
High risk of diabetes (HbA1c >6.5%)	9.8 (5.2 to 14.5)	<.001	7.0 (3.2 to 10.8)	<.001	2.9 (–2.8 to 8.6)	.32
High inflammation (CRP >0.3 mg/dL)	15.3 (8.3 to 22.3)	<.001	6.8 (1.6 to 12.0)	.01	8.5 (0.4 to 16.6)	.04
Self-reported physician-diagnosed conditions
Hypertension	19.2 (15.0 to 23.4)	<.001	12.2 (9.1 to 15.2)	<.001	7.0 (2.2 to 11.9)	.005
Arthritis	19.5 (16.4 to 22.6)	<.001	14.5 (11.5 to 17.5)	<.001	5.0 (1.1 to 8.9)	.01
Diabetes	12.4 (9.9 to 15.0)	<.001	8.2 (6.2 to 10.1)	<.001	4.3 (1.2 to 7.4)	.007
Heart problems	10.2 (7.9 to 12.6)	<.001	6.5 (4.3 to 8.6)	<.001	3.7 (0.7 to 6.8)	.02
Cancer	0.6 (–1.5 to 2.7)	.59	0.6 (–0.8 to 1.9)	.40	0.0 (–2.4 to 2.4)	>.99
Stroke	6.4 (5.0 to 7.8)	<.001	2.8 (2.0 to 3.7)	<.001	3.6 (2.0 to 5.2)	<.001
Chronic lung disease	10.7 (8.5 to 12.9)	<.001	4.6 (3.4 to 5.9)	<.001	6.0 (3.7 to 8.4)	<.001
Emotional/psychiatric	16.8 (14.6 to 18.9)	<.001	12.2 (10.1 to 14.3)	<.001	4.6 (1.6 to 7.6)	.003

Abbreviations: ADL, activities of daily living; BP, blood pressure; CES-D8, 8-item Center for Epidemiologic Studies Depression Scale; CRP, C-reactive protein; ELSA, English Longitudinal Study of Ageing; HbA_1c, hemoglobin A_1c; HRS, Health and Retirement Study; IADL, instrumental ADL.

SI conversion factors: To convert CRP to milligrams per liter, multiply by 10; HbA_1c to proportion of total Hb, multiply by 0.01.

^aAdjustment factors included age, year, sex, foreign-born status (outside the US for HRS; outside the UK for ELSA), race, household size, marital status. Estimates were calculated holding all adjustment factors at their grand mean values (ie, constant across countries and income groups). P values were determined from a t test of whether the estimate of difference in the adjusted prevalence was significantly different from 0.

Figure 2 presents the adjusted prevalence of poor health based on the self-assessed health outcomes for each income decile in each country. Adults in the US were more likely to report a functional limitation compared with those in England in all income groups, but the gap was greater in low-income groups (bottom decile: 75.7%; 95% CI, 72.7%-78.8% in HRS vs 59.5%; 95% CI, 56.3%-62.7% in ELSA; top decile: 35.1%; 95% CI, 31.9%-38.4% in HRS vs 29.1%; 95% CI, 26.2%-32.0% in ELSA). The adjusted prevalence of an IADL limitation was significantly greater for US adults in the lowest 2 income deciles (bottom decile: 25.9%; 95% CI, 23.3%-28.5% in HRS vs 18.9%; 95% CI, 16.2%-21.6% in ELSA; second decile: 24.7%; 95% CI, 21.2%-28.1% in HRS vs 17.5%; 95% CI, 15.0%-19.9% in ELSA), but was comparable for all other higher income deciles.

Figure 2. Adjusted Prevalence of Self-assessed Health Outcomes at Ages 55 to 64 Years for 2008-2016 by Country-Specific Income Decile.

Adjustment factors include age, year, sex, foreign-born status (outside the US for HRS; outside the UK for ELSA), race, household size, and marital status. Estimates were calculated holding all adjustment factors at their grand mean values (ie, constant across countries and income deciles). Error bars show 95% CIs. ADL indicates activities of daily living; ELSA, English Longitudinal Study of Ageing; HRS, Health and Retirement Study; and IADL, instrumental ADL.

The adjusted prevalence of the bottom 20% was significantly greater than that of the top 20% on all 3 directly measured health outcomes in the US (gap was 6.6 percentage points; 95% CI, 0.3-13.0 percentage points for high blood pressure; 9.8 percentage points; 95% CI, 5.2-14.5 percentage points for HbA_1c level, and 15.3 percentage points; 95% CI, 8.3-22.3 percentage points for CRP level) and on 2 outcomes in England (the gap was 7.0 percentage points; 95% CI, 3.2-10.8 percentage points for HbA_1c and 6.8 percentage points; 95% CI, 1.6-12.0 percentage points for CRP levels) (Table). This health gap by income (bottom 20% minus top 20%) was significantly greater in the US than England on high blood pressure (US-England difference in the gap was 8.2 percentage points; 95% CI, 1.1-15.3 percentage points) and elevated CRP level (US-England difference in the gap was 8.5 percentage points; 95% CI, 0.4-16.6 percentage points) (Table). The adjusted prevalence of poor health outcomes based on direct measures at each income decile is depicted in Figure 3.

Figure 3. Adjusted Prevalence of Measured Health Outcomes at Ages 55 to 64 Years for 2008-2016 by Country-Specific Income Decile.

Adjustment factors included age, year, sex, foreign-born status (outside the US for HRS; outside the UK for ELSA), race, household size, and marital status. Estimates were calculated holding all adjustment factors at their grand mean values (ie, constant across countries and income deciles). Error bars show 95% CIs. CRP indicates C-reactive protein; ELSA, English Longitudinal Study of Ageing; HbA_1c, hemoglobin A_1c; and HRS, Health and Retirement Study. SI conversion factors: To convert CRP to milligrams per liter, multiply by 10; HbA_1c to proportion of total Hb, multiply by 0.01.

There were substantial differences between the bottom 20% and the top 20% for all physician-diagnosed outcomes except cancer (Table), ranging from a 6.4 percentage point difference (stroke: 95% CI, 5.0-7.8 percentage points ) to a 19.5 percentage point difference (arthritis: 95% CI, 16.4-22.6 percentage points ) in the US and from a 2.8 percentage point difference (stroke: 95% CI, 2.0-3.7 percentage points ) to a 14.5 percentage point difference (arthritis: 95% CI, 11.5-17.5 percentage points) in England. This health gap by income (bottom 20% minus top 20%) was significantly greater in the US than England on all physician-diagnosed conditions except cancer (Table). The US-England difference in the gap was 7.0 percentage points (95% CI, 2.2-11.9 percentage points) for hypertension, 5.0 percentage points (95% CI, 1.1-8.9 percentage points) for arthritis, 4.3 percentage points (95% CI, 1.2-7.4 percentage points) for diabetes, 3.7 percentage points (95% CI, 0.7-6.8 percentage points) for heart problems, 3.6 percentage points (95% CI, 2.0-5.2 percentage points) for stroke, 6.0 percentage points (95% CI, 3.7-8.4 percentage points) for chronic lung disease, and 4.6 percentage points (95% CI, 1.6-7.6 percentage points). Figure 4 shows that, at all income levels, adults in the US were more likely to report a physician diagnosis of hypertension, arthritis, diabetes, and emotional/psychiatric problem, with a greater gap among the lower-income groups compared with the higher-income groups. For example, the adjusted prevalence of hypertension in the US vs England was 59.6% (95% CI, 55.2%-64.1%) vs 43.9% (95% CI, 40.6%-47.0%) (P < .001) for the bottom decile but 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for the top decile. The prevalence of arthritis in the US vs England was 53.9% (95% CI, 50.6%-57.2%) vs 37.6% (95% CI, 34.3%-40.8%) for the bottom decile and 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for the top decile. The adjusted prevalence of a heart problem, stroke, and chronic lung disease were comparable between the US and England for the higher income deciles, but significantly greater in the US for the lower income deciles (bottom decile: 21.0%; 95% CI, 18.7%-23.3% vs 16.4%; 95% CI, 14.0%-18.7% for heart problem; 7.6%; 95% CI, 6.0%-9.3% vs 3.8%; 95% CI, 2.6%-4.9% for stroke; and 13.8%; 95% CI, 11.3%-16.3% vs 7.3%; 95% CI, 5.8%-8.8% for chronic lung disease). Results from sensitivity analyses were mostly consistent with those from the main analyses (eFigure 5, eFigure 6, and eFigure 7 in the Supplement).

Figure 4. Adjusted Prevalence of Self-reported Physician-Diagnosed Health Conditions at Ages 55 to 64 Years for 2008-2016 by Country-Specific Income Decile.

Adjustment factors included age, year, sex, foreign-born status (outside the US for HRS; outside the UK for ELSA), race, household size, and marital status. Estimates were calculated holding all adjustment factors at their grand mean values (ie, constant across countries and income deciles). Error bars show 95% CIs. ELSA indicates English Longitudinal Study of Ageing; HRS, Health and Retirement Study.

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.

These findings persisted after adjusting for demographic factors, educational level, smoking, and body mass index. With the current data we were not able to assess the role of other factors in explaining these findings. We believe, however, that one important factor is that financial insecurity among low-income adults may lead to vulnerabilities that are not as well addressed in the US compared with England. We found that both the relative income and the absolute level of income were lower in the lowest income group among US adults aged 55 to 64 years compared with their peers in England. Both across and within countries, the lowest-income adults in the US had the worst outcome for nearly all 16 measures. At the same time, none of the 16 health outcomes were better in the US than England among the top 2 deciles despite having at least 80% higher income. Health care access appears to be more limited in the US due to the more complicated and fragmented health care system, and many US adults are uninsured, which may result in substantial out-of-pocket costs, especially among low-income individuals in the US. Social welfare programs in the US, separate from health care, are also limited compared with the UK system. These factors may be associated with worse overall health for lower-income US adults compared with those in England.

Limitations

Our study has limitations. First, questions regarding self-assessed health measures may be interpreted differently between countries owing to different health expectations and reference groups.³² Second, there may be systematic differences in the diagnosis of disease, such as screening and public awareness of symptoms, and other unobserved factors that influenced reporting of the physician-diagnosed health conditions. Third, directly measured health outcomes might not reflect the underlying health conditions across the US and England because of treatment differences between the countries. For example, self-reported diagnosis of hypertension was significantly higher in the US, but the rate of high blood pressure based on direct measurement was similar between the countries. Among those who reported a hypertension diagnosis, the rate of directly measured high blood pressure was significantly lower for US adults, suggesting more aggressive blood pressure treatment and/or diagnosis of less-severe cases in the US. Fourth, comparing health in only 2 countries limits the ability to identify the potential causes for cross-country differences in health. While income inequality is lower in England than the US, it is higher than in many other European countries, and England also has a more limited social welfare system than some other European countries.

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. 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. Future studies that better identify the factors, including individual, environmental, health system, and social welfare, that may be associated with the poor health of low-income US adults, would be valuable.

Supplement.

eTable 1. Summary of Covariates From US and England

eTable 2. Unadjusted Prevalence and Risk Ratios of Health Problems in the US vs. England at Ages 55-64 for 2008-2016

eTable 3. Median Household Income in the US and England, by Country-Specific Income Decile (unit: 2012 US $)

eFigure 1. Adjusted Risk Ratios (ARR) for Health Differences Between Non-Hispanic Whites in the US and Whites in England at Ages 55-64 for 2008-2016

eFigure 2. Adjusted Risk Ratios (ARR) for Health Differences Between the US and England at Ages 55-64 for 2008-2016, Applying for Additional Adjustments With Smoking and BMI

eFigure 3. Adjusted Risk Ratios (ARR) for Health Differences Between the US and England at Ages 55-64 for 2008-2016, Using Multiple Imputation Data

eFigure 4. Unadjusted Prevalence of Health Outcomes and Conditions at Ages 55-64 in the US and England for 2008-2016, By Income Percentile

eFigure 5. Adjusted prevalence of Health Outcomes and Conditions at Ages 55-64 for 2008-2016, by Income Decile, Using the Sample of Non-HispanicWhites in the US and Whites in England

eFigure 6. Adjusted Prevalence of Health Outcomes and Conditions at Ages 55-64 for 2008-2016, by Income Decile, With Additional Adjustments With Smoking and BMI

eFigure 7. Adjusted Prevalence of Health Outcomes and Conditions at Ages 55-64 for 2008-2016, by Income Decile, Using Multiple Imputation Data