Reducing income-related inequalities in care and health: insights from Israel

From a United States perspective, Amir Shmueli’s analysis of income-related inequalities
in health and healthcare in Israel is revealing 1]. Within the US we often attribute health disparities to lack of timely access and
affordability, in large part driven by lack of health insurance and gaps in insurance
benefits. As the Affordable Care Act begins to extend insurance, cover preventive
care in full, and provide substantial subsidies for the poor, the hope is that we
will see a substantial reduction in health disparities over time.

The Israeli experience that health disparities persist for some but not all conditions,
even when access is more equitable and affordable, provides insight for countries
beyond Israel. On a hopeful note, the study found no income-related differences in
asthma or cancer. This not the case in the United States where cancer rates and mortality
are higher in low-income communities, and asthma rates, especially complications from
asthma, are higher among those with low incomes 2].

However, the study finds that significant differences persist for heart, lung, depression,
and disability, with notably high income-related disparities for ADL limitations.
This is despite that fact that the poor in Israel have higher use of primary care.
Not surprisingly, given the higher rates of chronic disease, the Israeli poor also
have higher rates of hospital use than those with higher income.

As the author notes, the relationship between poor health and low income is not unidirectional.
Individuals and families with higher rates of disability or chronic conditions are
less likely to be able to work full time. And family members may need to take time
off from work to provide supportive care. At the same time, low-income imposes stress
on families and may signal individuals and families who are exposed to health risks
at work or in their communities (poor housing, environmental risk, healthy food or
exercise options, etc.)

Shmueli concludes that Israel’s health system functions equitably – especially in
comparison to several other countries. He then speculates that the key reasons for
persistent disparities in health outcomes are the use of preventive care, health behaviors,
and compliance with physician orders. The choice of these three reasons suggests remedies
from the medical care system and more effective use of medical care services. Selection
of these three reasons also suggests that patient behavior is a key concern rather
than health system responses/behavior or awareness of underlying health risks leading
to the observed poor health.

Disparities may well stem from workplace and community risks that undermine the health
of individuals and families with low income. Such “social determinants” of health
are known to put lower-income individuals and their families at particularly high
health risks 3]. Indeed, the study finding that income-related disparities persist even when access
to primary care is readily available and affordable, with particularly wide differences
in disability, point to the need to look beyond medical care and personal behaviors
to inform initiatives to close gaps.

Analyses of health service use and population health within the United States find
“hot spots” for health complications for children or adults; when mapped by very local
neighborhoods they reveal adverse living and working conditions 4]. Barriers to improving health may also arise from poor communication between patients
and physicians or care teams or lack of safe access (including privacy) to needed
care within communities. For example, Revital Gross’s analyses of women’s health and
care experiences among diverse vulnerable population in Israel indicated that family
relationships, attributes of communities, and less positive interactions or clear
communication with physicians could put women at risk 5]. Removing such barriers would require more patient-centered care teams and/or care
and support systems within and beyond local communities.

The study finding of significant disparities by income in the prevalence of heart
problems, lung problems, diabetes and disability but not asthma or cancer is notable.
Without further information on lifetime work, community and health service use, it
is impossible to understand factors contributing to the differences across these conditions.

However, one might speculate that ready access to medical care has particular benefits
for asthma and cancer in terms of early diagnosis, as well as effective treatment,
which could affect prevalence rates. In contrast, disability may arise from work or
environmental risks. Although medical care may ease pain or facilitate mobility, it
does not remove the income related difference in incidence or prevalence. Similarly,
heart disease and congestive heart failure may be the outcome of a lifetime of high
negative stress at work or in the community 6]. Medical care may moderate, but not remove, the negative consequences for health,
and hence is unlikely to affect disease prevalence.

Further research to asses work and family histories, and their association with disease
prevalence, could help inform strategies to reduce gaps by intervening early based
on an understanding of risk factors.