The United States Leads Other Nations In Differences By Income In Perceptions Of Health And Health Care
By Joachim O. Hero, Alan M. Zaslavsky and Robert J. Blendon
Health Affairs, June 2017
We examined income gaps in the period 2011–13 in self-assessments of personal health and health care across thirty-two middle- and high-income countries. While high-income respondents were generally more positive about their health and health care in most countries, the gap between them and low-income respondents was much bigger in some than in others. The United States has among the largest income-related differences in each of the measures we studied, which assessed both respondents’ past experiences and their confidence about accessing needed health care in the future. Relatively low levels of moral discomfort over income-based health care disparities despite broad awareness of unmet need indicate more public tolerance for health care inequalities in the United States than elsewhere. Nonetheless, over half of Americans felt that income-based health care inequalities are unfair, and these respondents were significantly more likely than their compatriots to support major health system reform — differences that reflect the country’s political divisions. Given the many provisions in the Affordable Care Act that seek to reduce disparities, any replacement would also require attention to disparities or risk taking a step backward in an area where the United States is in sore need of improvement.
From the Study Results
Views Related To Unmet Need And Fairness In Health Care
Perceptions of unmet health care need and income-based fairness norms varied widely across countries. Perceived unmet health care need in the United States was widespread, with 67 percent of respondents responding that “many” people in the country do not have access to the health care they need. This is over 10 percentage points higher than the level in any other country, and over twice the median country rate of 31 percent. 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 our sample. The proportion of respondents who believed that it is unfair that people with higher incomes can afford better health care than people with lower incomes was 54 percent in the United States, compared to the median country rate of 68 percent.
From the Discussion
The wide disparities in health care in the United States are natural consequences of features of its health care system. High out-of-pocket spending combined with fragmented and incomplete insurance coverage that is poorly targeted to meet economic need exacerbate sociodemographic drivers of disparity. These features expose Americans to catastrophic costs, which disproportionately affect low-income and disadvantaged groups. In spite of high poverty rates, the United States spends a smaller proportion of gross domestic product on social safety nets, compared to other high-income nations, and the constellation of services that can help improve health and access to health care is both less comprehensive and less generous.
Health care disparities are one of several interconnected aspects of US society that drive disparities in health. Poor living conditions and nutrition, unhealthy and stressful work environments, large income inequalities, and other factors have been linked to poor health in the United States, and all of them disproportionally affect low-income populations. In this way, wide disparities in health care are related to broader values systems in the United States that must also be addressed if gaps in health status are to be eliminated.
A current in recent research has addressed the role of norms of fairness in Americans’ attitudes about health care and the part those norms play in the divergence between health care policy in the United States and that of other nations. This research has found widespread concern among Americans about income-related health care disparities. The comparative evidence we presented above, while limited, stands in partial contrast to this work. We found that ethical concerns about the fairness of income-based health care disparities were less common in the United States than in most of the other countries in our sample, and that this norm of fairness reflects varied degrees of support for major health system reform. This is the case even though views that unmet need exists are more prevalent in the United States than in any other country in our sample. In all of the other high-income countries that had similarly low or lower concern about income-based health care inequalities than the United States — such as Australia, Finland, Great Britain, and Taiwan — most respondents believed that basic health care needs are being met.
By Don McCanne, M.D.
Ouch! Of 32 middle- and high-income countries studied, more Americans recognize that many people in the country do not have access to the health care they need, but Americans exhibit 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 studied.
The authors state, “We found that ethical concerns about the fairness of income-based health care disparities were less common in the United States than in most of the other countries in our sample, and that this norm of fairness reflects varied degrees of support for major health system reform. This is the case even though views that unmet need exists are more prevalent in the United States than in any other country in our sample.”
This suggests that our greatest barrier to enacting single payer reform is that too many Americans do not have ethical concerns about the lack of fairness of our income-based health care disparities. Yet we do not hear expressions of unfairness with our Medicare program. Do you suppose that, if we had an improved Medicare that covered everyone, most Americans might take pride in the fairness our our health care system? Let’s try it and see. It seems to work in other countries.