Health Inequality Aversion in the United States

OBJECTIVES: Health inequality aversion parameters are used in distributional cost-effectiveness analysis, direct equity-based weighting to reflect societal preferences for improving total health ("efficiency"), and reducing health inequality between more and less socially advantaged groups ("equity"). We elicited a health inequality aversion parameter for the US population. METHODS: We adapted a benefit trade-off (BTO) instrument used in a UK study. Participants comprised the adult general public from June to December 2023. The online survey comprised (1) demographics and health views questions, (2) instructional videos, and (3) BTO exercise. The BTO asked participants to trade off quality-adjusted life expectancy from the better-off to worse-off quintiles of the US population, described by indicators of social vulnerability. Response patterns were classified into 15 ranks with corresponding inequality aversion parameters and implied equity weights. RESULTS: Among 1864 complete responses, inequality aversion was assessed for 1290 participants. The sample approximated US Census data for gender, race/ethnicity, and income. The median Atkinson parameter was 12.12, the corresponding equity weight was 6.7, and 88% were willing to trade off total health to reduce health inequality. Multivariable regression indicated no significant subgroup variation in trade-off responses by age or region; however, lower income groups and ethnic minority groups were slightly more averse to health inequality. CONCLUSIONS: The inequality aversion statistics derived from this sample illustrate support for more robust and routine integration of equity concerns into healthcare decisions in the policy and health technology assessment arenas to advance distributional cost-effectiveness analysis in the United States.