Elsevier

Health Policy

Volume 67, Issue 3, March 2004, Pages 309-322
Health Policy

Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey

https://doi.org/10.1016/j.healthpol.2003.09.006Get rights and content

Abstract

Objective: To examine across five countries inequities in access to health care and quality of care experiences associated with income, and to determine whether these inequities persist after controlling for the effect of insurance coverage, minority and immigration status, health and other important co-factors. Design: Multivariate analysis of a cross-sectional 2001 random survey of 1400 adults in five countries: Australia, Canada, New Zealand, United Kingdom, and United States. Main outcome measures: Access difficulties and waiting times, cost-related access problems, and ratings of physicians and quality of care. Results: The study finds wide and significant disparities in access and care experience between US adults with above and below-average incomes that persist after controlling for insurance coverage, race/ethnicity, immigration status, and other important factors. In contrast, differences in UK by income were rare. There were also few significant access differences by income in Australia; yet, compared to UK, Australians were more likely to report out of pocket costs. New Zealand and Canada results fell in the mid-range of the five nations, with income gaps most pronounced on services less well covered by national systems. In the four countries with universal coverage, adults with above-average income were more likely to have private supplemental insurance. Having private insurance in Australia, Canada, and New Zealand protects adults from cost-related access problems. In contrast, in UK having supplemental coverage makes little significant difference for access measures. Being uninsured in US has significant negative consequences for access and quality ratings. Conclusions: For policy leaders, the five-nation survey demonstrates that some health systems are better able to minimize among low income adults financial barriers to access and quality care. However, the reliance on private coverage to supplement public coverage in Australia, Canada, and New Zealand can result in access inequities even within health systems that provide basic health coverage for all. If private insurance can circumvent queues or waiting times, low income adults may also be at higher risks for non-financial barriers since they are less likely to have supplemental coverage. Furthermore, greater inequality in care experiences by income is associated with more divided public views of the need for system reform. This finding was particularly striking in Canada where an increased incidence of disparities by income in 2001 compared to a 1998 survey was associated with diverging views in 2001.

Introduction

Inequities in access to medical care by income can contribute to and exacerbate disparities in health and quality of life. Conversely, policies that seek to promote equity in access for lower income individuals offer the potential of moderating underlying health differences and, over the longer term, providing more equal opportunities for health and productivity.

Countries vary widely in the extent to which public financing of health care and rules governing insurance markets seek to promote equity in access and health care experiences across income classes. Although the United States stands out among developed nations at one end of the spectrum for its lack of universal coverage, countries with universal coverage also differ in benefit design, patient-cost-sharing, and the role of private insurance. Non-financial barriers (such as waiting lists or queues, community shortages, complexity) as well as financial barriers may contribute to inequities in access. If private insurance enables more affluent families to have more ready access to care or to purchase a different standard of care, access inequities by income may emerge even where few financial barriers to health care exist.

In an era of budgetary constraints and often rapid changes in public health care policies, cross-national comparisons of access and care experiences by income offer the opportunity for countries to learn from each other and to assess relative performance. Yet, such comparative studies have been relatively rare due to lack of common access measures beyond physician visits or other measures of service use, and the lack of international studies using similar data-bases and time periods [1].

To assess access experiences and variations by income, the 2001 Commonwealth Fund International Health Policy Survey interviewed adults in five countries—Australia, Canada, New Zealand, United Kingdom and United States—using an array of questions on difficulties accessing medical care, financial barriers to obtaining needed health care, physician quality ratings, and overall health care system views. Previous descriptive analysis of this survey explored the extent to which experiences varied by income, without taking into account the effects of important confounding factors such as health insurance coverage, health status, education, race/ethnicity, immigration status, and residential location [2]. Each of these confounding factors can vary across income groups within each country as well as influence access and quality of care. Thus, failure to control for these effects could potentially bias any observed income-related inequities. In this paper, we re-examine the relative importance of low income and its association with access and care experiences disparities in Australia, Canada, New Zealand, United Kingdom, and the United States controlling for the effects of health insurance, health status, education, race/ethnicity, immigration status, and residential location. In addition, we examine the role of health insurance in minimizing income-related access and quality of care disparities. The analysis focuses on four central questions: How do access, cost, and adults’ perceptions of quality vary between low and higher income adults within each country? To what extent are access inequities by income attenuated after adjusting for insurance, health, and other characteristics likely to influence care experiences? In countries with universal coverage, how do access and care experiences vary depending on whether or not adults have private insurance in addition to public coverage? Do system views vary by income, and if so, are divergent system views more likely in countries with inequities in care experiences?

Section snippets

Methods and data

Data come from the 2001 Commonwealth Fund International Health Policy Survey, a five-nation survey consisting of interviews with a random sample of approximately 1400 adults age 18 and older in each of five countries: Australia (1412), Canada (1400), New Zealand (1400), United Kingdom (1400), and United States (1401). Conducted by telephone during April and May of 2001 by Harris Interactive, the survey explored problems accessing medical care, quality ratings, and adults’ views of their health

Country context: benefit coverage and role of private insurance

The health insurance systems in the five countries included in the study differ substantially with respect to the role of private insurance, the extent of patient cost-sharing, exposure to out of pocket costs for medical bills, and the range of benefits covered by public insurance systems. US stands out as the one country that does not provide universal coverage for at least a core set of benefits and for its reliance on a mixed system of voluntary private insurance and public coverage for the

Summary of country results and discussion

Overall, with respect to providing equity in access to care and health care experiences across income classes UK emerges as the most equitable and US as the least equitable. Among the five countries, UK generally stands out for the absence of income-related disparities in access and quality care. In UK, the gap between low and high income adults is typically small or non-existent. On only 2 out of 17 measures are responses by UK lower income adults more negative than those with above-average

Acknowledgements

The Commonwealth Fund funded the survey and analysis. The views are those of the authors and not necessarily those of the directors or officers of the Fund. This paper builds on an earlier article published in the US journal Health Affairs in May/June 2002. Authors of this paper were Robert Blendon, Cathy Schoen, Catherine DesRoches, Robin Osborn, Kimberly Scoles and Kinga Zapert. The authors thank Deirdre Downey at the Commonwealth Fund for preparation of tables, charts, and the manuscript. We

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