By Keren M. Escobar, Dorian Murariu, Sharon Munro, Kevin M. Gorey
Journal of Public Health Research, March 11, 2019
This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians’ chances of receiving better healthcare were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada’s single payer system ought to be maintained and strengthened, but not through privatization.
From the Introduction
Canadians and Americans rate health care a top concern. They seem naturally to wonder if health care policies are greener on the other side of their unfenced 5,000-kilometer border. Some Americans − particularly concerned with health care inaccessibility among the uninsured − have called for a more Canada-like single payer system. In contrast, some Canadians − concerned with health care shortages − have called for a more American-like system with more private options. Aiming to contribute critical evidence to these debates, our research group has focused on the health care of people living in poverty. We assume that this magnifies human and policy significance.
From the Discussion
This study found that Canadians with any number of acute health conditions or chronic diseases are significantly more advantaged on health care access and outcomes compared to their counterparts in the USA. It estimated that the chances of Canadians receiving indicated treatments and surviving were 13% greater than Americans. That estimate was more unequivocal and larger than previous review estimates that were based on less internally valid research designs. We advanced and found much support for a meta-analytic country by socioeconomic status interaction. This clearly demonstrated that Canadian advantages were significantly larger among those living in poverty or those who were otherwise socioeconomically vulnerable such as the uninsured or inadequately insured.
Among patients who lived in high poverty neighborhoods, it was estimated that the chances of Canadians receiving indicated treatments and surviving were 36% greater than Americans. That estimate was essentially unequivocal across all the reviewed studies and was larger than a previous meta-analytic estimate based on less prevalently poor neighborhoods. Recalling that such a 36% differential is implicated across most common health conditions and diseases over the lives of millions of impoverished Canadians and Americans, its population-level significance is clear. In addition to accounting for socioeconomic factors most of these primary studies also accounted for key personal and contextual case-mix differences between Canada and the USA, notably disease severity and health care service endowments in diverse large to small urban or rural places. We consider the robustness of the observed Canadian advantage to be our review’s most provocative scholarly and policy-significant finding.
As with primary research, we think that the interpretation of significant interaction effects or important effect modifications ought to take precedence in synthetic research. Therefore, we think four more interpretive adjuncts are in order. First, larger Canadian advantages were replicated among socioeconomically vulnerable patients with acute conditions and chronic diseases, representing a multiplicative Canadian advantage among those living in poverty with chronic diseases. Such patients probably had multiple experiences with their respective health care system over several years. In other words, it seems that the longer patients were in contact with their respective Canadian or American health care systems, the larger were their respective advantages or disadvantages. Second, three studies included four assessments of wait-lists, estimating that the exemplary risks of experiencing relatively long waits for adjuvant cancer care or of dying while waiting for a liver transplant were much greater in the USA (RRs ranged from 1.89 to 2.99, precision-weighted RR=2.36, 95% CI 2.09-2.66) than in Canada. This evidence stands in stark contrast to prevalent contemporary political rhetoric. Third, all this field’s synthetic evidence strongly suggests a dose-response relationship between socioeconomic vulnerability and Canadian advantages. It seems, therefore, that Canada’s single payer healthcare system causally provides much better health care than does the USA’s multiple payer system that still leaves millions uninsured or inadequately insured. The Canadian health care system’s most pronounced evidence-based advantages are clearly among those who live in poverty who consistently experience much better health care compared to impoverished Americans. In short, the more socioeconomically vulnerable a person is the more protective a single payer health care system is likely to be.
The fourth interpretive adjunct arose serendipitously in our systematic search for eligible studies. We retrieved 8 within-Canada studies of socioeconomic factors and cancer care. Though ineligible for this review, these studies were very interesting. One observed a modest indirect low-income-care association. Five others observed similar trends, but were not statistically significant and two others were null. The pooled precision-weighted estimate was minuscule (RR=0.97, 95% CI 0.95-0.99). We identified more than 100 such within-USA studies nearly all of which observed the well-known, large American socioeconomic-care gradient. Six studies that were included in this review, but that also observed typically very low-income or poverty associations with cancer care in both Canada and the USA allowed for a controlled, precision-weighted synthetic comparison. A large disadvantage of being poor was observed in the USA (RR=0.73, 95% CI0.71-0.75) while no such association was observed in Canada (RR=0.99, 95% CI 0.96-1.02), z=14.44, P<0.05. Such within-country observations clarify the between-country comparisons. Given the intimate relationship between low socioeconomic status and health insurance inadequacy in the USA, but not in Canada, the pattern resolutely identifies inadequate health insurance coverage in the USA as the primary explanation for this study’s findings. It clearly indicts the USA for the largely inadequate health insurance coverage it provides its underclass, including those who live in poverty or near poverty as well as the periodically unemployed or underemployed middle-class. Most regrettably, this indictment holds true in post-Affordable Care Act America. For example, at the time of this writing, 14 states still had not fulfilled the Act’s legislative intent to expand Medicaid.
This field’s research now seems rigorous enough to support confident judgements about the relative effectiveness of Canadian versus American health care, especially among the most socioeconomically vulnerable. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more equivocal and more modest Canadian advantages. The Affordable Care Act ought to be retained, indeed fully supported, including the envisioned expansion of Medicaid across all states. When politically achievable, however, single payer health care would better ensure truly equitable access and outcomes among America’s diverse population. Canada’s single payer system ought to be maintained and strengthened where needed, but not through the addition of private tiers.
Significance for Public Health
This study estimated that socioeconomically vulnerable Canadians’ chances of receiving better health care were 36% greater than their American counterparts and this estimate was larger than that based on general patient comparisons (9%). One may wonder about the public health significance of such relative risks/protections. Attributions of risk/protection among populations are a function of three factors of which relative risk is only one. The size of the population and the prevalence of exposure to risks are also important. In this instance, the entire USA population is at relatively greater risk of receiving lower quality care, its more prevalent low-income and inadequately insured populations more so. Applying our findings to population parameters and attributable risk formulations we estimated that without reform, over the next generation more than 50 million Americans will be treated less optimally and die earlier than had they enjoyed a single-payer health care system like Canada’s.
By Don McCanne, M.D.
Socioeconomically vulnerable residents of the United States fare much worse medically under our health care system than do socioeconomically vulnerable Canadians under their health care system. The authors of this meta-analysis estimate, “over the next generation more than 50 million Americans will be treated less optimally and die earlier than had they enjoyed a single-payer health care system like Canada’s.”
Solution? Single Payer Improved Medicare for All – Now!
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