Within the U.S., there is a wider disparity between how rich and poor people rate their own personal health status, more so than most other countries. However, the gap between how the rich and poor feel about the unfairness of the current U.S. health care system isn’t as great as it is in other countries.

These are the conclusions of a Harvard study published in the June issue of Health Affairs, “The United States Leads Other Nations In Differences By Income In Perceptions Of Health And Health Care.”

Joachim O. Hero, a Harvard doctoral candidate in health policy, and his colleagues analyzed population surveys from 2011 through 2013 from 32 high- and middle-income countries, and found the U.S. had the third-highest disparity in self-rated health -- behind Chile and Portugal -- at 25.9 percentage points, (which was unaffected by adjustment for insurance status, since the surveys were conducted before the implementation of the Affordable Care Act).

Among U.S. respondents, 38.2 percent in the bottom income tertile reported fair or poor health, compared to 21.4 percent in the middle tertile and 12.3 percent self-rate health in the top tertile.

Nonetheless, Americans exhibited less “moral concern” about income-based differences in the quality of health care that people have access to, compared to respondents in the majority of the other countries in the study.

The proportion of respondents who believe it is unfair that people with higher incomes can afford better health care than people with lower incomes was 54 percent in the U.S., compared to the median country rate of 68 percent.

The disconnect in the U.S. between perceptions of personal health among the income classes and concerns about the unfairness of the current health care system can be explained by the interconnected aspects of U.S. society that drive disparities in health, according to the study.

Poor living conditions and nutrition, unhealthy and stressful work environments, large income inequalities and other factors have been linked to poor health in the U.S., and all of them disproportionately affect low-income populations.

In an interview with BenefitsPRO, Hero says the disparities in health are really a product of a wide variety of social and economic factors, and don’t only include disparities in health care.

“If we really want to think about tackling the problem of health disparities comprehensively, there needs to be a connection between closing disparities across multiple sectors, including housing, education and workplace policies,” Hero says.

In finding solutions to address the disparity of health care access, it’s been difficult to gain political consensus because of the significant divisions between major segments of the American electorate, he says.

“There are competing values about the role of government and people’s personal responsibility -- the extent to which people’s health is determined by their own choices,” Hero says.

One way of reframing the debate could be to focus more on how health and access to health care are related to one’s opportunity to succeed, he says.

“We know Americans are more receptive to the concept of inequality of opportunities than they are to the concept of inequality of outcomes,” Hero says. “So if we can reinforce the idea that one’s health status is highly determinative of one’s economic opportunity, that can enhance one’s degree of political engagement and the ability to be represented in the political system.”

Even after adjusting for the increased level of insured people after the passage of the ACA, the study found that the U.S. remains one of the most “unequal countries” in the disparity of health care access among income levels, he says.

“In order to fully close the health care disparity gap, we also need to focus on disparities that exist among the population of insured people -- the differences in health plan affordability, cost-sharing across plans, coverage generosity, and how those differences are distributed among the population by income,” Hero says.

Instant Insights /

Study shows disparities between rich, poor on U.S. health & health care

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