The United States Leads Other Nations In Differences By Income In Perceptions Of Health And Health Care

Abstract

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.

Rawlsian Justice and the Social Determinants of Health

“…If absolute income is a social basis of health, this means that inequalities in income are permissible provided they are necessary to raise the income expectations of the least advantaged. 78 With respect to education, if education is a social basis of health, (2) requires that all people have equal opportunity to acquire it. (2) is thus no different from the principle of fair equality of opportunity, a key component of (3).…”

“…This does not mean that (2) demands that income must be distributed equally. First, it might be the case that only income disparities of a certain size contribute negatively to the health status of the least advantaged, meaning inequalities that do not reach this limit would be permissible.…”

“…Suppose further, however, that because relative income is a social basis of health, such inequalities would lead to worse health outcomes for those least advantaged on the social health gradient. Policies enabling these inequalities in income would satisfy (3) but they would not satisfy (2). Since (2) takes lexical priority over (3), the policies in question would be unjust.…”

“…Policies enabling these inequalities in income would satisfy (3) but they would not satisfy (2). Since (2) takes lexical priority over (3), the policies in question would be unjust.…”

“…As with relative income, this does not mean that (2) implies that inequalities in occupational rank are unjusti.e. that workplace hierarchies must be completely eliminated.…”