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Introduction: Socio-economic background is often an important determinant for health with low income households having higher exposure to risk factors and diminished access to healthcare and prevention, in a way that is specific to each country., Methods: Here, we perform a comparative analysis of the relations between health and income inequality in two developed countries, USA and Italy, using longitudinal and cross-sectional data from surveys., Results and Discussion: We show that the income class determines the incidence of chronic pathologies, associated risk-factors and psychiatric conditions, but find striking differences in health inequality between the two countries. We then focus our attention on a fraction of very disadvantaged households in the USA whose income in persistently at the bottom of the distribution over a span of 20 years and which is shown to display particularly dire health conditions. Low income people in the USA also display comorbidity patterns that are not found in higher income people, while in Italy income appears to be less relevant for comorbidity. Taken together our findings illustrate how differences in lifestyle and the healthcare systems affect health inequality., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 La Porta and Zapperi.)