Do Americans have higher mortality than Europeans at all levels of the education distribution?: a comparison of the United States and 14 European countries

Abstract

Among industrialized countries, the United States ranks near the bottom on life expectancy at birth. In 2006, the average American man and woman could expect to live 75 and 80 years, respectively, while the average Western European man and woman could expect to live 77 and 83 years, respectively (World Health Organization, 2009; World Health Organization Regional Office for Europe, 2010). Although the extent to which this is attributable to differences in the health care system is unknown, the United States spends two to three times more than other industrialized countries on medical care (Anderson and Hussey, 2001; Organisation for Economic Co-operation and Development, 2006). This suggests that at least part of the causes of the U.S. disadvantage might lie elsewhere. A plausible hypothesis is that disparities in mortality in the United States are larger than in other high-income countries, particularly in Western Europe. This implies that U.S. excess mortality might be attributable to higher excess mortality in those with low levels of education, while mortality levels for those with secondary or higher education might be comparable in Europe and the United States. Population composition is more diverse in the United States in terms of geography, race, and ethnicity, which may translate into larger health disparities than in Europe. Health care and social policies also differ dramatically between Europe and the United States. Most noticeably, while access to health care is nearly universal in Western Europe, about 41 million Americans remain uninsured (Adams, Dey, and Vickerie, 2007). In addition, compared with European countries, the United States has lower provision of social transfers (e.g., social retirement benefits, unemployment compensation, sick pay) and fewer redistributive policies, resulting in substantially larger income and wealth inequalities (Organisation for Economic Co-operation and Development, 2008; Wolf, 1996). Whether the less generous U.S. policies translate into larger mortality inequalities has not yet been established. The overall excess mortality in the United States compared with Western Europe is well documented (Organisation for Economic Co-operation and Development, 2006; World Health Organization, 2009). However, whether Americans of all education levels have higher mortality than comparable Europeans is yet unknown. Earlier mortality studies have focused only on the strength of education effects, yielding mixed results (Dahl et al., 2006; Kunst and Mackenbach, 1994; Mackenbach et al., 1999). Two recent studies suggest that although older Americans of all education, wealth, and income levels report poorer health than equivalent Europeans, the U.S. health disadvantage is largest among the poor and less educated (Avendano et al., 2009; Banks et al., 2006). Although based on cross-sectional and self-reported data, these findings support the hypothesis that larger health disparities in the United States partly explain the overall U.S. health disadvantage. A competing hypothesis is that Americans of all education levels experience higher mortality than equivalent Europeans. If true, one would expect U.S. residents of all education levels to have higher mortality rates than comparable Europeans. In this study, we examined cross-national differences in mortality by education level in the United States and 14 European countries in the 1990s and compared the magnitude of the disparities in mortality by education among these populations