European countries have for a long time emphasized health care systems based on equalitarian views, and the debate about health care reform is ongoing in the United States with multiple arguments for and against change. One important motivation discussed has been the income gradient in access to health care. While many have looked to more universal health care systems like those in Europe, it is not clear to what extent such institutional changes would suppress the relationship between income and health.

New research in the International Journal for Equity in Health from Dr Tinna Laufey Asgeirsdottir and Dr Dagny Osk Ragnarsdottir at the University of Iceland indicates that income-related health inequality is present in all 26 European countries, based on information from 440,000 individuals. The authors measured to what extent income-related health equality has been obtained in various European countries and evaluated the determinants of inequalities within countries, as well as cross-country patterns with regard to different institutional and social settings that have been hypothesized as possible suppressors of the relationship.

Two different measures of income are used in the calculations, (a) gross labor market income that shows how the individuals are rewarded in the labor market and (b) household income that takes governmental transfers into account, such as disability benefits, child relief, taxes and so forth, and is probably a better measure of an individual’s access to finances.

Surprisingly, cross-country patterns indicate that public spending on health plays a limited role in mitigation of the health-income inequality. Governmental transfers through taxes and benefits appear to be more important.

The findings imply that worse health is concentrated among the poorer in Europe. There are, however, substantial differences in health-income inequality between European countries. The results suggest that institutional determinants partly explain income-related health inequalities across countries. However, unexpectedly, public spending on health care is not systematically related to income-related health concentration. Also, not in accordance with conventional wisdom, is the result that those countries with high health-income inequality tend to be the countries spending the most on education. This however supports previously published theories hypothesizing social mobility as the explanation for differences in health-income inequalities.

The production of health and the mitigation of the health-income relationship has been the focus of large-scale government expenditures and the study sheds light on the effectiveness of discussed policies in mitigating this inequality. Universal coverage is a large scale policy, involving other aspects, such as adverse selection, that were not a part of this analysis but need to be taken into account. However, based on the European experience, universal coverage and public expenditures on health-care systems available to the whole population do not appear to mitigate the health-income relationship.