The United States between 2011 and 2013 had one of the largest disparities in health outcomes among high- and low-income residents in the world, according to a study published Monday in Health Affairs.

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For the study, researchers analyzed population survey data from 32 high- and middle-income nations collected between 2011 and 2013—before the Affordable Care Act's coverage expansions took effect. The researchers sought to determine and compare the level of disparity in each nation based on three main measures: self-reported health, access to care, and doctor visit satisfaction.

Key findings

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The researchers found that among U.S. residents in households with annual incomes of $22,500 or less, 38 percent said they were in "fair or poor" health—a rate more than three times the 12 percent of U.S. respondents in households with annual incomes of $47,700 per year who reported the same. According to the researchers, among the 32 nations studied, only Chile and Portugal reported a greater divide in health outcomes between high- and low-income individuals than the United States.

The study also found that 1 in 5 respondents from lower-income U.S. households said they could not access needed health care because of the cost, compared with about 1 in 25 respondents from the higher-income households. On this measure, the United States was outranked by only one nation, the Philippines.

Moreover, the study found that U.S. residents from lower-income households were more likely than those from higher-income households to say they were dissatisfied with their last visit to a doctor.

Overall, according to the researchers, the only other countries in the study who reported such large gaps between high- and low-income residents for all three measures were Bulgaria, Chile, Portugal, and Russia. "The United States exhibited large disparities in most measures, making it unique among high income countries," the researchers wrote.

But the researchers also found that Americans' attitudes toward health disparities varied from other nations .While two-thirds of U.S. respondents said "many" Americans could not access needed health care—10 percentage points more than any other nation studied—U.S. respondents were less likely to say it is unfair for wealthier people to have better access to care. According to the study, 54 percent of U.S. respondents said it was "somewhat unfair" or "very unfair" that people from higher-income households received better care, compared with the median rate of 68 percent across all examined countries

The researchers acknowledged that their data were pulled from a time period before many major parts of the ACA took effect, including Medicaid expansion and the creation of the law's health insurance exchanges. However, when the researchers adjusted their data to account for those coverage gains, they found that the overall disparities decreased just a minor amount.

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Looking beyond coverage to reduce disparities

While the researchers cautioned that "any policy change that threatens the insurance gains seen since the [ACA's] implementation would likely reverse any improvement in income-based health care disparities that may have followed," they said policymakers should look beyond coverage to reduce disparities.

"Insurance is part of the story but not the whole story," Joachim Hero, lead study author, said. "If we really want to bring the United States more in line with other high-income countries with regard to health-care disparities, we're going to have to go beyond just achieving full insurance coverage."

Hero also pointed to the questions raised by U.S. respondents' perception that "many" Americans do not have access to needed health care and that it's not necessarily unfair for wealthy people to have better health care access. "The combination of those two things raises this question: Is there a lack of political will to address the issue of disparities in the United States, relative to countries where we know they do a lot better on this issue?" Hero asked (Khazan, The Atlantic, 6/5; Johnson, "Wonkblog," Washington Post, 6/5).