Neighborhood socioeconomic inequalities in healthcare costs: the role of lifestyle behaviors

Socioeconomic inequalities in healthcare costs are large, but the underlying behavioral mechanisms remain unclear. We examined how neighborhood socioeconomic status (NSES) and lifestyle behaviors-physical activity (PA), sport participation, smoking, and alcohol use-jointly relate to healthcare costs in the Netherlands. Using a population-wide ecological dataset of 6213 neighborhoods, we linked relative (i.e. age- and sex-standardized) healthcare costs with survey-based estimates of lifestyle behaviors. Linear regression models estimated the associations between lifestyle factors and relative healthcare costs, adjusting for demographic and urbanization characteristics. Additional models stratified by NSES decile assessed socioeconomic modification of lifestyle-cost associations. A strong socioeconomic gradient in relative healthcare costs was observed; the most deprived NSES decile having €1096 higher average costs than the most affluent decile. NSES alone explained over €300 of this inter-decile cost gap. Across all neighborhoods, each 1-percentage-point higher sport participation, PA adherence, and smoking prevalence were associated with cost changes of -€14.27 (95% CI -16.96 to -11.59), -€6.96 (95% CI -9.59 to -4.32), and +€22.06 (95% CI 17.96 to 26.16), respectively; alcohol use showed no association. Within-decile analyses revealed strong protective effects of sport in the most deprived neighborhoods (-€37.26, 95% CI -47.54 to -26.97) and consistent cost increases associated with smoking across all deciles. Lifestyle-cost associations differ markedly by socioeconomic context. Structured sport participation shows the greatest cost-saving potential in disadvantaged neighborhoods, while smoking remains the dominant cost driver nationwide. Addressing behavioral inequalities is key to narrowing socioeconomic disparities in healthcare expenditures.