Poorer, Less Educated People in the United States in Worse Health Than Their Counterparts in Canada

(PORTLAND, Ore.)—Analysis of the largest survey directly comparing health in the United States and Canada reveals significant disparities between some citizens of the two countries. Although overall population health is similar in both countries, the survey shows important health disparities associated with age, gender, education, income, marital status, and country of residence. The most dramatic differences are associated with income and education – people in the U.S. at the lowest income level and at lower levels of education are significantly less healthy than those in Canada with the same income and education. These findings appear in the December issue of Population Health Metrics.


“Income and education are well-known predictors of health status,” says health economist David Feeny, PhD, senior investigator at Kaiser Permanente’s Center for Health Research and co-author of the study. “What was surprising, however, was the statistically significant health gap between people in the U.S. and Canada at the lowest levels of income and education. The question is, what explains this gap? A reasonable proposition is that differences in social and economic inequality between the two countries may account for the health disparities. Compared to the U.S., Canada’s wider social safety net and its universal healthcare insurance system appear to lead to better health for its citizens with less income and education. One would hope these survey findings might inform the American healthcare debate during the coming elections.”

These findings are from the Joint Canada/United States Survey of Health (JCUSH), a telephone survey on the health of community-dwelling residents in Canada and the U.S. conducted between November 2002 and March 2003. The same questions were asked in both countries, and the same methodologies were used to score answers and analyze results. A total of 8,688 people responded to the survey (3,505 in Canada and 5,183 in the U.S.). Respondents were asked to rate their overall health (poor, fair, good, very good, excellent) and to rate eight attributes of their current health status – vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain.

Responses were analyzed using the Health Utilities Index Mark 3 (HUI3), a preference-based measure of health-related quality of life that translates people’s assessment of their health into a simple score on a scale ranging from 0.00 (“dead”) to 1.00 (“perfect health”). Differences of 0.03 or more in overall health status are considered to be clinically important. For example, scores for people at the highest income level were the same in the U.S. and Canada (HUI3 score of 0.93), as were scores for those with a university degree (0.92). However, scores for people in Canada at the lowest income level were 0.81, compared to 0.77 in the U.S., and 0.81 compared to 0.74 for people with less than a high school diploma. These differences in overall health of 0.04 (income) and 0.07 (education) are clinically important for comparing the health of both populations.

“Race is also a factor in health status,” says Ken Eng, MA, co-author of the study and a former member of the Institute of Health Economics, Edmonton, Canada. “Because the United States has a much higher percentage of minorities than Canada, we wondered how much race might be contributing to the striking health disparities we found. So we also analyzed the data for white survey respondents only and found the same pattern of health status – similar levels of excellent health among white Canadians and Americans at the highest levels of income and education but striking health disparities between white Canadians and Americans at the lowest levels of income and education.”

Funding for this study of the Joint Canada/United States Survey of Health was provided by grants from the Alberta Heritage Foundation for Medical Research and the Institute of Health Economics.

Kaiser Permanente’s Center for Health Research, founded in 1964, is a non-profit research institution whose mission is advancing knowledge to improve health. It has research facilities in Portland, OR; Honolulu, HI; and Atlanta, GA.

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