those with lower education, a number of other countries have similar differentials.

Studies in both Europe and the United States have noted the significant role of behavioral differences in partially explaining differentials in mortality by socioeconomic status (Cutler et al., 2010; Mackenbach and Garssen, 2010; Meara et al., 2008). However, these same studies have noted that these behavioral factors do not explain most of the differentials by socioeconomic status in health, nor do they explain most of the trend. An exception is Jha and colleagues (2006), who used the Peto/Lopez method described in Chapter 7 to estimate deaths attributable to smoking at ages 35–69 among three social classes in the United States, England and Wales, Canada, and Poland. They found that a majority of the difference in mortality between the lowest and highest classes in each of these countries is attributable to smoking.

DISCUSSION

Much of this chapter has examined differences in mortality by educational level in the United States and other countries, viewing education, as an indicator of socioeconomic status, as a fundamental cause of inequalities in health. With respect to income inequalities, it is widely believed that such inequalities are greater in the United States than in other high-income countries, in part because the United States does less to redistribute wealth among its citizens (Organisation for Economic Co-operation and Development, 2008; Wolf, 1996). Poverty rates also appear to be higher in the United States than in most of the other countries considered here, as evidenced by further data from the OECD study indicating the proportion of the population below half-median income, or by micro-level data on the ratio of income at the 10th percentile relative to median income (Krueger et al., 2009).

Furthermore, a large number of people in the United States, especially at lower levels of socioeconomic status, have no health insurance, while most Western European countries have national health care coverage programs. It is also true that people in the United States are less protected from loss of either income or wealth because of health problems than those in most Western European countries. Health problems are a major reason for bankruptcy in the United States, and this is less likely to be the case in Europe or Japan (Himmelstein et al., 2005). We have also seen that socioeconomic differentials in smoking tend to be larger in the United States than in other countries.

This combination of factors could result in higher mortality rates among people in lower socioeconomic brackets in the United States than in other countries, pulling down U.S. life expectancy levels in general. This possi-



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement