# Inequities in the Hypertension and Diabetes Care Cascade: A Comparison of SES and Insurance in China, the US, and the UK

## TL;DR

This study compares how socioeconomic status and health insurance affect hypertension and diabetes care in China, the US, and the UK.

## Contribution

The study reveals how health systems and insurance structures influence care disparities in chronic disease management across three countries.

## Key findings

- China's care cascade for hypertension and diabetes showed the largest disparities, linked to fragmented insurance systems.
- In the US, health insurance improved diagnosis and treatment but not disease control, suggesting financial barriers persist.
- The UK had the most equitable access due to universal coverage, but wealth and education still influenced diabetes outcomes.

## Abstract

Background/Objectives: Socioeconomic status (SES) and health insurance are critical determinants of chronic disease outcomes. This study evaluates their impact on the hypertension and diabetes “care cascade” (diagnosis, treatment, and control) across three distinct health systems: China, the United States (US), and the United Kingdom (UK). Methods: We analyzed cross-sectional data from pooled survey waves of the China Health and Retirement Longitudinal Study (CHARLS), the US National Health and Nutrition Examination Survey (NHANES), and the English Longitudinal Study of Ageing (ELSA). The final analytic sample comprised a total of 46,054 participants with hypertension and 11,805 with diabetes. Logistic regression model was employed to estimate the associations of education, wealth, and health insurance with disease management outcomes. Results: Significant cross-national heterogeneity was observed. China exhibited the steepest attrition in the care cascade, with disparities strongly linked to insurance fragmentation; notably, Urban Employee Insurance was associated with significantly better outcomes compared to the Rural Cooperative Medical Scheme. In the US, health insurance was strongly associated with diagnosis and treatment initiation but showed attenuated associations with disease control, suggesting that financial barriers (“underinsurance”) may persist. The UK demonstrated the highest equity in access due to universal National Health Service coverage, though education remained a predictor for diabetes identification; moreover, a persistent wealth-based gradient in disease control remained despite universal access. Conclusions: Universal health coverage effectively mitigates access barriers but does not eliminate inequalities driven by cumulative socioeconomic disadvantage. Achieving equity requires context-specific strategies: reducing insurance fragmentation in China, minimizing out-of-pocket costs in the US, and addressing upstream social determinants in the UK.