Wealth and health in Europe
and the United States
Mauricio Avendano, Erasmus Medical Center
Maria Glymour, Harvard School of Public Health
Johan Mackenbach, Erasmus Medical Center
RAND Corporation
Santa Monica, 10 July 2006
Inequality is larger in the US than in
any other EU country…
Gini coefficients of income in 27 OECD countries, 2000
Ir
Au l
s
Jp
n
Sp
a
G
re
Ita
Po
U r
SA
Po
l
Tu
r
OECD average
D
k
Se
N
l
Au
C t
ze
Lu
x
Fi
n
N
or
C
h
Be
l
Fr
a
G
er
H
u
C n
an
50
45
40
35
30
25
20
15
10
OECD wealth and social statistics, 2005
But SES disparities in mortality were
not clearly different between countries
in the late 1980s…
Rate ratio of mortality by educational level, 1988
1.6
Rate ratio
1.5
1.4
All causes
CVD
1.3
1.2
1.1
1
US
Finland
Norway
italy
Cze
Hungary
Mackenbach, J.P. Am J Public Health. 1999.
Estonia
Background & Objectives
•
•
•
Wealth reflects SES better: assets accumulation,
predicts mortality at old age (Robert, 1996)
Equalitarian policies: ‘Social democratic’ (northern Europe)
vs. ‘liberal’ regimes (US) (Esping-Anderson, 1999)
Research questions:
1. Variations in (relative) wealth and physical health
associations across Europe and the US
2. Are Wealth and health associations independent
of other SES indicators?
3. Explaining wealth disparities in health: Lifestyle,
depression, and healthcare utilization
Data and methods
• 50 years or older
• Health and retirement survey:
– 7th Wave 2004 (similar results with weighted 2002 wave)
– Non-Hispanic whites
– n=14,303
• Share study:
– 2004 wave for 10 countries
– n=21,596
• Age & sex standardized rates – logistic regression:
 Healthi
Logit ( Health Outcomei ) = Log 
 1 − Healthi
α 4Countryi × Wealth qu int ilei + ε i

 = α 0 + α1 Agei + α 2 Sexi + α 3Countryi +

Measures
• Relative wealth:
– Total net worth
– Financial assets
– Real assets
Country
quintiles
Physical health:
–
–
–
–
–
–
Self-perceived health (US version, ‘bad or very bad’)
Cardiovascular (stroke or heart) disease
Cancer
1+ ADL limitations (e.g., dressing, bathing, eating)
Grip strength (kg)
Walking speed (m/s)
1. Wealth & Physical Health
Relative wealth gradient is clear in all
countries, but slightly steeper in the US than
EU
Adjusted prevalence of poor health by total net worth quintile
Poor or very poor health
60%
50%
5th
4th
3rd
2nd
1st
40%
30%
20%
10%
0%
Se
Dk
De
Nl
Adjusted for age & sex
Fr
Ch
Au
It
Es
Gre
EU
US
Wealth gradient is similar for both financial
and real assets
A d ju s te d
p re v a le n c e o f p o o r h e a lth
q u in t il e
b y t o t a l f in a n c ia l a s s e t s
Poor or very poor health
6 0 %
5 0 %
5
4
3
2
1
4 0 %
3 0 %
2 0 %
th
th
rd
n d
s t
1 0 %
0 %
S e
D k
D e
N l
F r
C h
A u
It
E s
G re
E U
U S
A d j u s t e d p r e v a l e n c e o f p o o r h e a l t h b y r e a l a s s e t s q u in t il e
Poor or very poor health
6 0 %
5 0 %
5
4
3
2
1
4 0 %
3 0 %
2 0 %
1 0 %
0 %
S e
D k
D e
Adjusted for age & sex
N l
F r
C h
A u
It
E s
G re
E U
U S
th
th
rd
nd
st
CVD prevalence is higher, and wealth
gradients are steeper in the US than in
Europe…
Adjusted prevalence of poor health by total net worth quintile
60%
Prevalence CVD
50%
5th
4th
3rd
2nd
1st
40%
30%
20%
10%
0%
Se
Dk
De
Adjusted for age & sex
Nl
Fr
Ch
Au
It
Es
Gre
EU
US
And prevalence of limitations with adl1+ is
highest in poorest quintile in the US , Danish
and France…
Adjusted prevalence of reporting 1 or more ADL limitatations by
total net worth quintile
30%
1+ ADL limitations
25%
5th
4th
3rd
2nd
1st
20%
15%
10%
5%
0%
Se
Dk
De
Adjusted for age & sex
Nl
Fr
Ch
Au
It
Es
Gre
EU
US
…But mostly real assets drive associations
of wealth with adl in several EU countries
R e a l a s s e ts q u in tile
30%
1+ ADL limitations
25%
20%
5
4
3
2
1
15%
10%
th
th
rd
nd
st
5%
0%
S e
D k
D e
Nl
Fr
C h
A u
It
E s
G re
E U
US
F in a n c ia l a s s e ts q u in tile
30%
1+ ADL limitations
25%
20%
5
4
3
2
1
15%
10%
5%
0%
Se
D k
D e
Nl
Fr
C h
Au
It
Es
G re
EU
US
th
th
rd
nd
st
Surprisingly, cancer is a lot more prevalent
in the US, and appears to be more prevalent
in the richest wealth quintile!
Adjusted prevalence of cancer by total net worth quintile
20%
18%
Cancer prevalence
16%
5th
4th
3rd
2nd
1st
14%
12%
10%
8%
6%
4%
2%
0%
Se
Dk
De
Adjusted for age & sex
Nl
Fr
Ch
Au
It
Es
Gre
EU
US
US has relatively low grip strength, but
differences between wealth quintiles are
remarkably similar across countries….
Mean max. grip strength by total net worth quintile
Mean Max. grip strength (Kg)
39
37
35
5th
3rd
1st
33
31
29
27
25
Se
Dk
De
Adjusted for age & sex
Nl
Fr
Ch
Au
It
Es
Gre
EU
US
Higher WS and larger disparities in north EU
and US, lower WS and smaller disparities in
Austria, Spain, Greece…
Walking speed by total net worth quintile
Mean walking speed (m/s)
1.2
1
0.8
5th
3rd
1st
0.6
0.4
0.2
0
Se
Dk
De
Adjusted for age & sex
Nl
Fr
Ch
Au
It
Es
Gre
EU
US
2. Is the association between wealth and
health independent of education and
income?
Wealth disparities in CVD are larger in
the US than in EU….
O d d s r a t i o o f c a r d i o v a s c u la r d i s e a s e b y t o t a l n e t w o r t h
q u i n t i le
4 .5
Odds ratio CVD
4
3 .5
5 th % ti le
4 th % ti le
3 r d % ti le
2 n d % t i le
1 s t% ti le
3
2 .5
2
1 .5
1
0 .5
EU
US
T o ta l n e t w o r th
4 .5
Odds ratio 1+ADL
4
3 .5
5 t h % t i le
4 t h % t i le
3 r d % t i le
3
2 .5
2 n d % t i le
1 s t % t i le
2
1 .5
1
0 .5
E U
Adjusted for age & sex
U S
And they are largely independent from
education and income…
Odds ratio CVD
Odds ratio of cardiovascular disease by total net worth quintile
3
2.8
2.6
2.4
2.2
2
1.8
1.6
1.4
1.2
1
United
States
Basic
+inc, edu
European
Union
Basic: age & sex
5th
4th
3rd
2nd
1st
5th
4th
3rd
2nd
1st
Total net worth
Odds ratio 1+ADL
3.3
United
States
2.8
2.3
Basic
+inc, edu
1.8
1.3
0.8
5th
4th
3rd
2nd
1st
5th
4th
3rd
2nd
1st
2. Is the association between wealth
and health independent of risk factors,
depression and healthcare utilization?
Health behavior, depression, and
healthcare utilization partly attenuate
wealth disparities in health…
To ta l n e t w o r th
2 .2
U n i te d
S ta te s
Odds ratio CVD
2
B a s ic
H e a lth b e h a vo u r
D e p r e s s io n
H e a lth c a r e u s e
A ll fa c to r s
1 .8
1 .6
Eu ro p e a n
U n io n
1 .4
1 .2
1
5 th
4 th
3rd
2nd
1st
5 th
4 th
3rd
2nd
1st
T o ta l n e t w o r th
Basic: age, sex &
education
Odds ratio 1+ADL
3 .3
U n ite d
S ta te s
2 .8
B a s ic
H e a lth b e h a vo u r
E u ro p e a n
U n io n
2 .3
D e p re s s i o n
H e a lth c a re u s e
1 .8
A ll fa c to rs
1 .3
0 .8
5 th
4 th
3 rd
2 nd
1st
5 th
4 th
3 rd
2 nd
1st
Conclusions
• Wealth is negatively associated with health in all countries
• Health gap between 20% richest and 20% poorest is
generally larger in the US than in Europe for self-reported
measures…
• ….But not clearly for objective health measures
• Real assets are more strongly related to disability than
financial assets
housing conditions?
• Adjustment for health behavior, depression and health care
use moderately attenuated wealth disparities, which remain
substantial after full adjustment…
Interpretation & implications
• Relative vs. absolute –wealth absolute disparities larger in
the US: Redistribution of wealth?
• …But wealth inequality unrelated to wealth inequality in
health within Europe
• Objective health indicators:
– Self-report
– Different dimensions of health
• Wealth – health - wealth (reverse causation)