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PLoS One. 2014 Jan 8;9(1):e83705. doi: 10.1371/journal.pone.0083705. eCollection 2014.

Impact of universal health insurance coverage on hypertension management: a cross-national study in the United States and England.

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Department of Primary Care Health Sciences, University of Oxford, Oxford, England.
Department of Primary Care and Public Health, Imperial College London, London, England.
Institute for Health and Human Development, University of East London, London, England.
Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America.



The Patient Protection and Affordable Care Act (ACA) galvanised debate in the United States (US) over universal health coverage. Comparison with countries providing universal coverage may illustrate whether the ACA can improve health outcomes and reduce disparities. We aimed to compare quality and disparities in hypertension management by socio-economic position in the US and England, the latter of which has universal health care.


We used data from the Health and Retirement Survey in the US, and the English Longitudinal Study for Aging from England, including non-Hispanic White respondents aged 50-64 years (US market-based v NHS) and >65 years (US-Medicare v NHS) with diagnosed hypertension. We compared blood pressure control to clinical guideline (140/90 mmHg) and audit (150/90 mmHg) targets; mean systolic and diastolic blood pressure and antihypertensive prescribing, and disparities in each by educational attainment, income and wealth, using regression models.


There were no significant differences in aggregate achievement of clinical targets aged 50 to 65 years (US market-based vs. NHS--62.3% vs. 61.3% [p = 0.835]). There was, however, greater control in the US in patients aged 65 years and over (US Medicare vs. NHS--53.5% vs. 58.2% [p = 0.043]). England had no significant socioeconomic disparity in blood pressure control (60.9% vs. 63.5% [p = 0.588], high and low wealth aged ≥65 years). The US had socioeconomic differences in the 50-64 years group (71.7% vs. 55.2% [p = 0.003], high and low wealth); these were attenuated but not abolished in Medicare beneficiaries.


Moves towards universal health coverage in the US may reduce disparities in hypertension management. The current situation, providing universal coverage for residents aged 65 years and over, may not be sufficient for equality in care.

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