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The SES health gradient on both sides of the Atlantic

Book chapter

In this paper we investigate the size of health differences that exist among men in England and the United States and how those differences vary by Socio-Economic Status (SES) in both countries. Three SES measures are emphasized - education, household income, and household wealth - and the health outcomes investigated span multiple dimensions as well. International comparisons have played a central part of the recent debate involving the 'SES health gradient' with some authors citing cross-country differences in levels of income equality and mortality as among the most compelling evidence that unequal societies have negative impacts on individual health outcomes. In spite of the analytical advantages of making such international comparisons, until recently good micro data measuring both SES and health in comparable ways have not been available for both countries. Fortunately, that problem has been remedied with the fielding of two surveys - the Health and Retirement Survey (HRS) and the English Longitudinal Survey of Aging (ELSA). In order to facilitate the type of research represented in this paper, both the health and SES measures in ELSA and HRS were purposely constructed to be as directly comparable as possible. Our analysis presents data on some of the most salient issues regarding the social health gradient in health and the manner in which this health gradient differs for men across the two countries in question. There are a several key findings. First, looking across a wide variety of diagnosed diseases, average health status among mature men is much worse in America compared to England, confirming non-gender specific findings we reported in earlier research. Second, there exists a steep negative health gradient for men in both countries where men at the bottom of the economic hierarchy are in much worse health than those at the top. This social health gradient exists whether education, income, or financial wealth is used as the marker of SES. While the negative social gradient in male health characterizes men in both countries, it appears to be steeper in the United States. These central conclusions are maintained even after controlling for a standard set of behavioral risk factors such as smoking, drinking, and obesity and are equally true using either biological measures of disease or individual self-reports. In contrast to these disease based measures of health, the health of American men appears to be superior to the health of English men when self-reported subjective general health status is used as the measure of health status. This apparent contradiction does not result from differences in co-morbidity, emotional health, or ability to function all of which still point to mature American men being less healthy than their English counterparts. The contradiction most likely stems instead from different thresholds used by Americans and English when evaluation their health status on subjective scales. For the same 'objective' health status, Americans are much more likely to say that their health is good than are the English. Finally, we present preliminary data that indicates that feedbacks from new health events to household income are also one of the reasons that underlie the strength of the income gradient with health in England. Previous research has demonstrated its importance as one of the underlying causes in the United States and these results suggest that that conclusion should most likely be extended to England as well although further research is required on this topic.

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Journal article published in the Journal of Health Economics in September 2020. Full (open-access) article available at https://www.sciencedirect.com/science/article/pii/S016762962030014X?via%3Dihub