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

Richard H. Glazier; Mohammad M. Agha; Rahim Moineddin; Lyn M. Sibley

doi:10.1370/afm.994

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Figure 1.
Utilization of at least 1 office visit by specialty, adjusted for sociodemographic characteristics, self-reported morbidity, and diagnosis-based morbidity.

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Table 1.

Sociodemographic and Morbidity Measures by Sex for Population-Weighted Canadian Community Health Survey, 2000–2001 for Ontario, and Johns Hopkins Adjusted Clinical Groups, 2001–2002

Variable	All	Female	Male	PValue
CCHS = Canadian Community Health Survey.
^aEducational attainment categorized as low (not completed high school), medium (high school completion and some postsecondary education), and high (university degree). Values missing for 0.7% of respondents.
^bIncome defined using total household income adjusted for the number of people living in the household and categorized as low (Statistics Canada’s lowest and lower-middle income), medium (upper-middle income), and high (highest income). For a household with 2 or fewer people, income levels correspond with Canadian dollar incomes of <$30,000, $30,000-59,999, and ≥$60,000, respectively. Values missing for 9.0% of respondents.
CCHS measures
Mean age, y	45.6	47.1	44.1	<.001
Educational attainment, %^a
Low	18.3	19.3	17.4
Medium	30.8	32.5	29.3
High	50.9	48.2	53.3	<.001
Income, %^b
Low	26.9	30.8	23.3
Medium	34.4	34.1	34.7
High	38.7	35.1	42.0	<.001
Poor-fair self-rated health, %	12.8	13.8	11.9	<.001
≥2 Chronic conditions, %	41.6	49.6	34.3	<.001
Depression, %	11.7	14.9	8.8	<.001
Disability, %	13.9	18.9	9.4	<.001
Adjusted Clinical Groups
≥6 Aggregated diagnosis groups, %	30.3	38.9	22.4	<.001
≥4 Resource utilization bands, %	12.1	14.1	10.3	<.001

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Table 2.

Distribution of Morbidity Measures by Education and Income, Population-Weighted Canadian Community Health Survey, 2000–2001, for Ontario, and Johns Hopkins Adjusted Clinical Groups, 20001–2002

		Education^a					Income^b
Morbidity Measure	Age, y	High %	Medium %	Low %	Rate Ratio	95% CI	High %	Medium %	Low %	Rate Ratio	95% CI
CCHS = Canadian Community Health Survey.
Note: Rate ratio for high/low education and income.
^a Educational attainment categorized as low (not completed high school), medium (high school completion and some postsecondary education), and high (university degree). Values missing for 0.7% of respondents.
^b Income defined using total household income adjusted for the number of people living in the household and categorized as low (Statistics Canada’s lowest and lower-middle income), medium (upper-middle income), and high (highest income). For a household with 2 or fewer people, income levels correspond with Canadian dollar incomes of <$30,000, $30,000-59,999, and ≥$60,000, respectively. Values missing for 9.0% of respondents.
CCHS measures
Poor-fair self-rated health
Female	20–44	5.8	7.0	17.9	0.32	0.21–0.44	3.5	5.9	13.1	0.27	0.24–0.31
	45–79	13.1	16.8	32.0	0.41	0.34–0.48	9.7	17.1	31.3	0.31	0.16–0.37
Male	20–44	3.6	6.4	16.2	0.22	0.13–0.31	3.2	6.1	10.4	0.31	0.23–0.39
	45–79	12.8	18.6	33.1	0.39	0.32–0.45	9.9	17.5	35.2	0.28	0.19–0.43
All	20–79	8.3	11.4	28.0	0.30	0.26–0.33	6.3	11.5	22.8	0.28	0.22–0.34
Chronic conditions ≥2
Female	20–44	34.5	35.5	48.0	0.72	0.61–0.82	33.8	36.6	38.9	0.87	0.74–1.00
	45–79	57.2	59.4	69.9	0.82	0.77–0.87	52.4	63.2	68.0	0.77	0.71–0.83
Male	20–44	23.4	23.1	30.4	0.77	0.63–0.91	21.4	25.4	26.0	0.82	0.68–0.96
	45–79	43.5	47.5	53.3	0.82	0.75–0.88	41.4	44.7	55.8	0.74	0.67–0.81
All	20–79	37.9	39.8	55.2	0.69	0.65–0.72	35.5	41.9	48.2	0.74	0.69–0.78
Depression
Female	20–44	14.9	18.9	20.0	0.75	0.55–0.94	13.8	16.4	20.1	0.69	0.53–0.83
	45–79	12.5	13.3	14.0	0.89	0.68–1.10	12.1	13.0	15.2	0.80	0.58–1.01
Male	20–44	8.5	9.5	19.1	0.45	0.32–0.56	7.0	10.0	15.5	0.45	0.33–0.58
	45–79	7.2	7.4	7.9	0.91	0.65–1.18	5.2	8.1	9.4	0.55	0.38–0.72
All	20–79	10.6	12.4	13.6	0.78	0.68–0.87	9.1	11.7	15.2	0.60	0.52–0.68
Disability
Female	20–44	8.4	8.4	18.8	0.45	0.29–0.60	6.6	8.6	14.2	0.46	0.33–0.60
	45–79	21.8	24.3	38.4	0.57	0.49–0.64	18.3	25.9	36.0	0.51	0.42–0.60
Male	20–44	3.2	3.6	11.4	0.28	0.15–0.41	3.3	3.5	8.1	0.41	0.23–0.59
	45–79	12.2	15.4	22.9	0.53	0.43–0.64	8.7	14.1	28.2	0.31	0.24–0.38
All	20–79	10.5	12.2	26.4	0.40	0.36–0.44	8.5	12.7	22.4	0.38	0.33–0.43
Adjusted Clinical Groups
Aggregated diagnosis groups ≥6
Female	20–44	28.7	34.2	38.0	0.75	0.61–0.90	29.2	31.2	34.3	0.85	0.72–0.98
	45–79	41.6	45.1	50.8	0.82	0.74–0.90	40.9	44.4	49.2	0.83	0.75–0.92
Male	20–44	13.2	14.4	20.3	0.65	0.49–0.81	11.8	15.1	17.3	0.68	0.50–0.87
	45–79	29.4	32.6	37.2	0.79	0.69–0.89	26.7	33.2	39.6	0.68	0.58–0.77
All	20–79	26.7	30.4	39.7	0.67	0.63–0.72	25.4	30.3	35.9	0.71	0.66–0.76
Resource utilization bands ≥4
Female	20–44	6.6	9.0	13.6	0.49	0.43–0.56	7.3	7.6	9.4	0.78	0.52–1.03
	45–79	17.7	17.2	23.8	0.74	0.28–0.69	14.6	16.5	25.9	0.56	0.46–0.67
Male	20–44	3.9	4.1	10.4	0.38	0.61–0.87	3.4	4.4	7.0	0.48	0.24–0.72
	45–79	14.6	16.1	23.1	0.63	0.22–0.53	13.2	17.0	22.0	0.60	0.47–0.73
All	20–79	9.9	10.8	20.1	0.49	0.52–0.75	9.0	11.1	16.5	0.54	0.47–0.62

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Table 3.

Patient Utilization of Family Physicians/General Practitioners and Specialists by Education and Income, Population-Weighted Canadian Community Health Survey, 2000–2001, for Ontario, and Ontario Health Insurance Plan Claims, 2002–2004

		Education^a,b					Income^a,c
Variable^d	Age, y	High %	Medium %	Low %	Rate Ratio	95% CI	High %	Medium %	Low %	Rate Ratio	95% CI
CI=confidence interval; FP/GP = family physician/general practitioner.
Note: Rate ratio for high/low education and income.
^a Data from the Canadian Community Health Survey.
^b Educational attainment categorized as low (not completed high school), medium (high school completion and some postsecondary education), and high (university degree). Values missing for 0.7% of respondents.
^c Income defined using total household income adjusted for the number of people living in the household and categorized as low (Statistics Canada’s lowest and lower-middle income), medium (upper-middle income), and high (highest income). For a household with 2 or fewer people, income levels correspond with Canadian dollar incomes of <$30,000, $30,000-59,999, and ≥$60,000, respectively. Values missing for 9.0% of respondents.
^d Data from the Ontario Health Insurance Plan Claims.
FP/GP visits ≥1
Female	20–44	91.1	89.9	91.7	0.99	0.96–1.03	92.4	89.6	89.4	1.03	1.00–1.07
	45–79	91.4	90.9	92.5	0.99	0.96–1.01	91.8	91.5	91.2	1.01	0.98–1.03
Male	20–44	81.9	81.1	79.7	1.03	0.96–1.09	81.8	80.0	81.0	1.01	0.96–1.06
	45–79	87.6	87.0	86.2	1.02	0.98–1.05	84.9	90.0	85.8	0.99	0.95–1.03
All	20–79	87.4	86.9	88.2	0.99	0.97–1.01	87.0	87.4	87.2	1.00	0.98–1.02
FP/GP visits ≥10
Female	20–44	29.3	31.8	42.8	0.68	0.54–0.82	26.9	34.3	33.3	0.81	0.68–0.93
	45–79	38.7	47.5	55.7	0.69	0.63–0.76	37.8	47.4	51.0	0.74	0.66–0.82
Male	20–44	14.0	15.1	20.2	0.69	0.50–0.89	13.4	13.6	19.0	0.70	0.50–0.91
	45–79	33.4	38.5	43.3	0.77	0.69–0.85	31.4	39.3	44.0	0.71	0.62–0.81
All	20–79	27.4	31.7	44.1	0.62	0.58–0.66	25.9	32.8	37.6	0.69	0.64–0.74
Specialist visits ≥1
Female	20–44	52.3	51.5	56.0	0.93	0.82–1.04	52.5	51.5	53.9	0.97	0.88–1.06
	45–79	68.2	70.9	72.9	0.94	0.88–0.99	67.8	70.1	71.9	0.94	0.89–1.00
Male	20–44	39.1	33.2	38.0	1.03	0.86–1.20	37.7	34.9	39.9	0.95	0.82–1.08
	45–79	64.3	63.1	64.6	0.99	0.93–1.06	62.0	66.1	64.2	0.97	0.90–1.04
All	20–79	54.3	52.7	62.3	0.87	0.84–0.91	53.2	54.8	58.2	0.91	0.88–0.95
Specialist visits ≥5
Female	20–44	16.3	17.9	17.9	0.91	0.64–1.18	15.4	17.8	18.8	0.82	0.62–1.01
	45–79	35.1	34.8	36.9	0.95	0.85–1.06	32.2	37.0	37.9	0.85	0.74–0.96
Male	20–44	9.5	9.1	14.3	0.66	0.44–0.89	9.0	10.0	11.0	0.82	0.55–1.08
	45–79	30.5	32.1	32.7	0.93	0.82–1.05	28.2	35.0	35.0	0.81	0.69–0.92
All	20–79	21.4	22.0	29.4	0.73	0.67–0.79	20.0	23.7	26.9	0.74	0.70–0.83

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Table 4.

Patient Utilization of Family Physicians/General Practitioners by Education and Income, Population-Weighted Canadian Community Health Survey, 2000–2001, for Ontario, and Ontario Health Insurance Plan Claims, 2002–2004

	≥1 FP/GP Visits vs No Visit^a		≥10 FP/GP Visits vs <10 Visits^a
Patient Characteristic	Partially Adjusted OR (95% CI)	Fully Adjusted OR (95% CI)	Partially Adjusted OR (95% CI)	Fully Adjusted OR (95% CI)
CCHC = Canadian Community Health Survey; CI = confidence interval; FP/GP = family physician/general practitioner; OR = odds ratio.
^aAdjusted for sociodemographic characteristics, self-reported morbidity, and diagnosis-based morbidity.
^bEducational attainment categorized as low (not completed high school), medium (high school completion and some postsecondary education), and high (university degree). Values missing for 0.7% of respondents.
^cIncome defined using total household income adjusted for the number of people living in the household and categorized as low (Statistics Canada’s lowest and lower-middle income), medium (upper-middle income), and high (highest income). For a household with 2 or fewer people, income levels correspond with Canadian dollar incomes of <$30,000, $30,000-59,999, and ≥$60,000, respectively. Values missing for 9.0% of respondents.
CCHC measures
Educational attainment^b
High	1.02 (0.84–1.20)	1.05 (0.87–1.24)	0.66 (0.57–0.75)	0.77 (0.65–0.88)
Medium	0.95 (0.78–1.12)	0.99 (0.80–1.18)	0.79 (0.68–0.90)	0.91 (0.77–1.05)
Low (reference)	1.00	1.00	1.00	1.00
Income^c
High	1.11 (0.94–1.28)	1.14 (0.95–1.33)	0.71 (0.61–0.81)	0.85 (0.72–0.98)
Medium	1.10 (0.92–1.27)	1.09 (0.90–1.28)	0.90 (0.78–1.01)	1.02 (0.87–1.16)
Low (reference)	1.00	1.00	1.00	1.00
Location
Urban	1.05 (0.90–1.20)	0.98 (0.83–1.12)	1.31 (1.14–1.47)	1.23 (1.05–1.41)
Rural (reference)	1.00	1.00	1.00	1.00
Age (continuous)	1.01 (1.01–1.02)	1.00 (0.99–1.00)	1.04 (1.03–1.04)	1.02 (1.02–1.03)
Sex
Female	1.95 (1.71–2.18)	1.44 (1.24–1.63)	1.65 (1.49–1.81)	1.26 (1.12–1.40)
Male (reference)	1.00	1.00	1.00	1.00
Self-rated health
Fair-poor	—	0.69 (0.53–0.85)	—	1.74 (1.44–2.03)
Good	—	0.95 (0.79–1.12)	—	1.28 (1.11–1.44)
Very good/excellent (reference)	—	1.00	—	1.00
Chronic conditions ≥2
Yes	—	1.34 (1.15–1.54)	—	1.34 (1.19–1.50)
No (reference)	—	1.00	—	1.00
Depression
Yes	—	1.05 (0.81–1.29)	—	1.08 (0.90–1.26)
No (reference)	—	1.00	—	1.00
Disability		0.84 (0.64–1.03)		1.18 (0.99–1.37)
Yes	—		—
No (reference)	—	1.00	—	1.00
Adjusted Clinical Groups
Aggregated diagnosis groups
≥10 (high)	—	3.19 (1.61–4.78)	—	6.82 (5.00–8.65)
6–9 (medium)	—	3.07 (2.29–3.86)	—	2.81 (2.46–3.16)
0–5 (low) (reference)	—	1.00	—	1.00
Resource utilization bands
≥4 (very high)	—	2.80 (1.89–3.72)	—	3.53 (2.32–4.74)
3 (high)	—	5.29 (4.40–6.17)	—	4.29 (3.04–5.54)
2 (medium)	—	2.68 (2.23–3.13)	—	2.26 (1.55–2.97)
0–1 (low) (reference)	—	1.00	—	1.00

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Table 5.

Patient Utilization of Specialists by Education and Income, Population-Weighted Canadian Community Health Survey, 2000–2001, for Ontario, and Ontario Health Insurance Plan Claims 2002–2004

	≥1 Specialist Visit vs No Visit^a		≥5 Specialist Visit vs <5 Visits^a
Patient Characteristic	Partially Adjusted OR (95% CI)	Fully Adjusted OR (95% CI)	Partially Adjusted OR (95% CI)	Fully Adjusted OR (95% CI)
CI=confidence interval; OR = odds ratio.
^aAdjusted for sociodemographic characteristics, self-reported morbidity, and diagnosis-based morbidity.
^bEducational attainment categorized as low (not completed high school), medium (high school completion and some postsecondary education), and high (university degree). Values missing for 0.7% of respondents.
^cIncome defined using total household income adjusted for the number of people living in the household and categorized as low (Statistics Canada’s lowest and lower-middle income), medium (upper-middle income), and high (highest income). For a household with 2 or fewer people, income levels correspond with Canadian dollar incomes of <$30,000, $30,000-59,999, and ≥$60,000, respectively. Values missing for 9.0% of respondents.
CCHC measures
Educational attainment^b
High	1.06 (0.93–1.18)	1.22 (1.07–1.37)	1.04 (0.88–1.19)	1.23 (1.03–1.42)
Medium	0.99 (0.87–1.12)	1.12 (0.97–1.26)	1.04 (0.86–1.22)	1.19 (0.99–1.40)
Low (reference)	1.00	1.00	1.00	1.00
Income^c
High	0.98 (0.88–1.08)	1.12 (0.99–1.24)	0.88 (0.76–1.00)	1.05 (0.90–1.20)
Medium	0.95 (0.85–1.05)	1.02 (0.90–1.13)	1.00 (0.86–1.13)	1.12 (0.96–1.29)
Low (reference)	1.00	1.00	1.00	1.00
Location
Urban	1.29 (1.16–1.41)	1.22 (1.10–1.34)	1.22 (1.07–1.37)	1.19 (1.03–1.34)
Rural (reference)	1.00	1.00	1.00	1.00
Age (continuous)	1.04 (1.04–1.04)	1.03 (1.02–1.03)	1.04 (1.03–1.04)	1.03 (1.02–1.03)
Sex
Female	1.55 (1.42–1.67)	1.21 (1.10–1.31)	1.18 (1.04–1.32)	1.04 (0.90–1.17)
Male (reference)	1.00	1.00	1.00	1.00
Self-rated health
Fair-poor	—	1.24 (1.05–1.43)	—	1.66 (1.37–1.95)
Good	—	1.12 (1.00–1.24)	—	1.24 (1.06–1.42)
Very good/excellent (reference)	—	1.00	—	1.00
Chronic conditions ≥2
Yes	—	1.32 (1.19–1.45)	—	1.12 (0.97–1.26)
No (reference)	—	1.00	—	1.00
Depression
Yes	—	1.08 (0.92–1.24)	—	1.08 (0.90–1.25)
No (reference)	—	1.00	—	1.00
Disability
Yes	—	1.15 (0.98–1.33)	—	1.15 (0.97–1.33)
No (reference)	—	1.00	—	1.00
Adjusted Clinical Groups
Aggregated diagnosis groups
≥10 (high)	—	3.02 (2.17–3.87)	—	2.34 (1.76–2.92)
6–9 (medium)	—	1.89 (1.67–2.10)	—	1.37 (1.18–1.56)
0–5 (low) (reference)	—	1.00	—	1.00
Resource utilization bands
≥4 (very high)	—	3.31 (2.53–4.10)	—	2.76 (1.85–3.68)
3 (high)	—	2.79 (2.38–3.21)	—	1.85 (1.36–2.33)
2 (medium)	—	1.71 (1.44–1.98)	—	1.22 (0.88–1.57)
0–1 (low) (reference)	—	1.00	—	1.00

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The Article in Brief

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

Richard H. Glazier , and colleagues

Background Does universal coverage of physician services reduce socioeconomic disparities in health care? If so, to what degree? Researchers in Canada, which has universal coverage of necessary physician services, examined equity in the use of those services.

What This Study Found Universal health insurance appears to reduce income inequities but not education-related disparities in physician services. Those with higher levels of education are more likely to see specialists, to be frequent visitors to the doctor, and to bypass primary care to reach specialists compared with those with lower levels of education.

Implications

One explanation for the study findings may be that patients with higher levels of education have better health knowledge, which leads to greater demand for care and better ability to navigate the health care system.
The authors suggest that policy makers consider the advantage of providing universal physician coverage as a means to reduce income inequities, although this strategy alone is unlikely to eliminate educational disparities in use of physician services.

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