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Vickerie, 2007). In addition, compared with European countries, the United States has lower provision of social transfers (e.g., social retirement benefits, unemployment compensation, sick pay) and fewer redistributive policies, resulting in substantially larger income and wealth inequalities (Organisation for Economic Co-operation and Development, 2008; Wolf, 1996). Whether the less generous U.S. policies translate into larger mortality inequalities has not yet been established.

The overall excess mortality in the United States compared with Western Europe is well documented (Organisation for Economic Co-operation and Development, 2006; World Health Organization, 2009). However, whether Americans of all education levels have higher mortality than comparable Europeans is yet unknown. Earlier mortality studies have focused only on the strength of education effects, yielding mixed results (Dahl et al., 2006; Kunst and Mackenbach, 1994; Mackenbach et al., 1999). Two recent studies suggest that although older Americans of all education, wealth, and income levels report poorer health than equivalent Europeans, the U.S. health disadvantage is largest among the poor and less educated (Avendano et al., 2009; Banks et al., 2006). Although based on cross-sectional and self-reported data, these findings support the hypothesis that larger health disparities in the United States partly explain the overall U.S. health disadvantage. A competing hypothesis is that Americans of all education levels experience higher mortality than equivalent Europeans. If true, one would expect U.S. residents of all education levels to have higher mortality rates than comparable Europeans.

In this study, we examined cross-national differences in mortality by education level in the United States and 14 European countries in the 1990s and compared the magnitude of the disparities in mortality by education among these populations.


European Data

We obtained data on mortality according to age, sex, education level, and cause of death from mortality registries. In most countries, data were collected in a longitudinal design, by linking mortality data to 1990s census data in a follow-up period using personal identifiers. However, for some Eastern European and Baltic countries, only cross-sectional data were available around the 2000 census. The data comprise entire national populations, except for the United Kingdom, with data for England and Wales only. For countries with a follow-up period of 10 years or longer, the baseline was ages 30-74. For countries with follow-up shorter than 10 years, the baseline age comprised a broader age group to avoid bias due to variations

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