Study: Health worsening among less-educated adults over last 20 years

Patient and nurse in hospital
Health disparities among more and less-educated adults are widening within the white population. (Getty/monkeybusinessimages)

Despite expanded healthcare coverage for the vulnerable, health disparities for less-educated Americans still exist, according to a new study from the Robert Wood Johnson Foundation (RWJF).

All less-educated adults—across racial, ethnic and geographical lines—have seen worsening health between 1997 and 2017, especially within the increases in obesity. And the biggest growth in health disparity has been among white adults with more or less education. Conversely, health disparities for black adults with a high school degree or less narrowed slightly since 2011.

The research, conducted by the Urban Institute, began in 2011 and will continue as an ongoing project. Looking at the past two decades, health disparities between adults with and without a college education have remained quite stagnant other than a slight narrowing in 2011, possibly due in part to the Affordable Care Act (ACA). And racial disparities in health outcomes between black and white people with a high school degree or less declined between 1997 and 2017, the study found.

As demonstrated in previous studies, adults with less education have a lower life expectancy and an increased risk for chronic conditions compared with more educated adults. Wealth is associated with more access to health insurance coverage and greater economic resources to support eating well and exercising. Moreover, studies have found that adults with less education experience greater chronic stress than those with college degrees.

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Because each of the mechanisms through which education affects health may also vary by race, ethnicity and geography, the RWJF study examines these trends separately for non-Hispanic white, non-Hispanic black and Hispanic adults, as well as for those living in urban and rural areas.

Overall, adults reported worsening health between 1997 and 2017 across the board. Specifically, adults with less education in fair or poor health increased by 31% from 1997 to 2017, from 12.8% to 16.8% of the population. Less-educated adults also experienced a 19% increase in activity limitation, a 16% increase in moderate or severe psychological distress and a 50% increase in obesity.

Over the study period, the composition of more and less-educated groups changed. For example, adults with a high school degree became more likely to be aged 45 to 64, male and a minority.

At the same time, more older, non-white and female adults were attaining higher education. This change in population demographics did not affect the rates of obesity, but it did change the demographics of those psychologically distressed to more adults with less education. Overall, disparity widened over time for general health, activity limitation and psychological distress.

Looking at race and ethnicity, black adults with less education reported worse general health and obesity than white or Hispanic adults, but black and white adults had similar outcomes on activity limitations and psychological distress.

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White adults in fair or poor health increased by 41% over the time period, compared with a 22% increase for Hispanics and a 15% increase for black adults, according to the study. Plus, activity limitations for less-educated white adults increased 39%, compared with 12% among black adults and remaining flat for Hispanic adults. And for physiological distress, there was almost no change over time for Hispanic and black adults, compared with a 40% increase for less-educated white adults.

In short, by 2017, the black-white gaps in activity limitation and obesity were no longer statistically significant, and the gap in psychological distress had reversed, with less-educated white adults reporting higher rates of psychological distress than their black counterparts.

“Though our preliminary analysis found that the ACA likely played a minor role in driving these changes, additional analysis of the role of insurance and other factors in explaining these patterns is warranted," the authors wrote. "Given the large coverage gains under the ACA for all groups we examined and only modest improvements in disparities for a few groups, our results clearly imply that insurance is not the only solution to the health disparities facing less-educated adults."

"This further suggests the need for interventions aimed at reducing non-insurance-related resource constraints, improving health literacy, and alleviating sources of chronic stress among adults with a high school degree or less,” the study concluded.