Universal Health Insurance and Equity in Primary Care and Specialist Office Visits: A Population-Based Study

By Richard H. Glazier, MD, MPH, Mohammad M. Agha, PhD, Rahim Moineddin, PhD and Lyn M. Sibley, PhD
Annals of Family Medicine
September/October 2009
Universal coverage of physician services should serve to reduce socioeconomic disparities in care, but the degree to which a reduction occurs is unclear. We examined equity in use of physician services in Ontario, Canada, after controlling for health status using both self-reported and diagnosis-based measures.
CONCLUSIONS After adjusting for health status, we found equity in contact with primary care for educational attainment but inequity in specialist contact, frequent visits, and bypassing primary care. In this setting, universal health insurance appears to be successful in achieving income equity in physician visits. This strategy alone does not eliminate education-related gradients in specialist care.
http://www.annfammed.org/cgi/content/full/7/5/396

Much of the discussion on health care reform centers around financing reform, with goals of achieving universality and affordability. Effective reform that would actually accomplish that (i.e., single payer) would be a crucial first step toward the even more important goal of reducing the socioeconomic disparities in care. The record on disparities in the United States is shameful.
This study looks at inequities in a country that has already established an equitable, universal financing system for health care: Canada. Three important conclusions: 1) Physician visits for both primary care and specialists were equitable regardless of the income level of the patient, 2) Physician visits for primary care were equitable regardless of the level of the educational achievement of the patient, and 3) Patients with a higher level of educational achievement had greater contact with specialists, often bypassing primary care.
Think of how Canada must struggle with this policy issue. They must determine whether more educated individuals are obtaining an excessive quantity of specialized services, or if those with less education are being deprived of specialized services they should have. Then they have to decide on policies that would improve access or reduce waste, as appropriate.
Compare that to the policy issues we face in the United States. We have a financing system that creates personal financial hardships, results in physical suffering and sometimes even death, and wastes hundreds of billions of dollars that could be redirected to paying for health care services that people need and are not receiving. Canada has passed that hurdle long ago.
Wouldn’t it be nice if we could also be working on the minutiae of health policy instead of the most fundamental changes that we desperately need? Unfortunately, Congress, in moving forward with tweaking the private insurance industry, has decided to work on the minutiae and ignore the basics. Tweaks can never fix a fundamentally flawed financing structure that must first be replaced before it can be tweaked.

By Richard H. Glazier, MD, MPH, Mohammad M. Agha, PhD, Rahim Moineddin, PhD and Lyn M. Sibley, PhD
Annals of Family Medicine
September/October 2009

Universal coverage of physician services should serve to reduce socioeconomic disparities in care, but the degree to which a reduction occurs is unclear. We examined equity in use of physician services in Ontario, Canada, after controlling for health status using both self-reported and diagnosis-based measures.

CONCLUSIONS After adjusting for health status, we found equity in contact with primary care for educational attainment but inequity in specialist contact, frequent visits, and bypassing primary care. In this setting, universal health insurance appears to be successful in achieving income equity in physician visits. This strategy alone does not eliminate education-related gradients in specialist care.

http://www.annfammed.org/cgi/content/full/7/5/396

Comment:

By Don McCanne, MD

Much of the discussion on health care reform centers around financing reform, with goals of achieving universality and affordability. Effective reform that would actually accomplish that (i.e., single payer) would be a crucial first step toward the even more important goal of reducing the socioeconomic disparities in care. The record on disparities in the United States is shameful.

This study looks at inequities in a country that has already established an equitable, universal financing system for health care: Canada. Three important conclusions: 1) Physician visits for both primary care and specialists were equitable regardless of the income level of the patient, 2) Physician visits for primary care were equitable regardless of the level of the educational achievement of the patient, and 3) Patients with a higher level of educational achievement had greater contact with specialists, often bypassing primary care.

Think of how Canada must struggle with this policy issue. They must determine whether more educated individuals are obtaining an excessive quantity of specialized services, or if those with less education are being deprived of specialized services they should have. Then they have to decide on policies that would improve access or reduce waste, as appropriate.

Compare that to the policy issues we face in the United States. We have a financing system that creates personal financial hardships, results in physical suffering and sometimes even death, and wastes hundreds of billions of dollars that could be redirected to paying for health care services that people need and are not receiving. Canada has passed that hurdle long ago.

Wouldn’t it be nice if we could also be working on the minutiae of health policy instead of the most fundamental changes that we desperately need? Unfortunately, Congress, in moving forward with tweaking the private insurance industry, has decided to work on the minutiae and ignore the basics. Tweaks can never fix a fundamentally flawed financing structure that must first be replaced before it can be tweaked.