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

This paper makes some important headway in the research on inequities in the use of health care. Especially in Canada where a fundamental objective is to ensure that health care is delivered on the basis of need and not ability to pay, research over the past decades has provided us with good evidence on the extent of inequity in health care utilization. Less is known about the mechanisms through which people with socioeconomic advantage, whether with higher income or higher education (or, as is most common, both), use more services than individuals without such an advantage but with similar levels of health.

The authors find relatively little inequity in primary care and in the specialties for more life-threatening conditions, which represents an important achievement. The strongest effect of education is on use of services in the two specialties with some gaps in public coverage - dermatology and ophthalmology services. For example, routine eye exams are not insured or are insured in limited intervals for the general working-age population in most provinces. The study also finds an education effect on bypassing primary care to access specialists, a plausible pathway by which the better educated are more likely to access specialist care than those with less education but with similar levels of health.

If these are some of the causes, then what are the solutions? If policymakers in Canada are concerned with the apparently inequitable use of dermatology and ophthalmology, then decisions could be made to increase public coverage of these services, in particular for lower income groups. It does not appear to be of concern, however, since the trend has been in the opposite direction in many provinces in recent years (Stabile & Ward, 2006); therefore the level of inequity is likely to increase in those jurisdictions. The education effect on utilization is less clearly relevant to policy, since it relates to individuals preferences; although in a referral-based system as in Canada’s, it is important to ensure that patients in lower socioeconomic groups receive appropriate referrals to specialist care (Chan & Austin, 2003).

References

Chan, B. T., & Austin, P. C. (2003). Patient, physician, and community factors affecting referrals to specialists in Ontario, Canada: a population-based, multi-level modelling approach. Medical Care, 41(4), 500-511.

Stabile, M., & Ward, C. (2006). The Effects of Delisting Publicly Funded Health Care Services. In R. Chaykowski, S. Shortt, F. St-Hilaire & A. Sweetman (Eds.), Health Services Restructuring in Canada: New Evidence and New Directions, John Deutsch Institute for the Study of Economic Policy pp. 83-110). Kingston: McGill/Queen’s University Press.

Competing interests:   None declared