Achieving Horizontal Equity

A comparison between London, Paris, and Manhattan explores the effect of their respective health care systems on access to care. In the end, the French, although far from perfect, appear to have the most equitable system.

As lawmakers returned home during their August recess, potential design changes to the American health care system stirred heated and passionate debate. While many Americans can support simple changes to the health care system – such as forbidding the practice excluding insurance applicants because of pre-existing conditions – controversial aspects of health reform, notably the debate over a “public plan,” threaten to derail health reform. 

This timely study sheds light on a major philosophical sticking point for stakeholders on both sides of the debate. Is single-payer national health insurance necessary to achieve health equity for people of disparate socioeconomic backgrounds? Advocates such as Physicians for a National Health Program suggest that universal health care must have a single payer (such as in the British National Health Service or the United States Medicare program). Others might argue that a transition to a single-payer system might destroy the very features that permit the United States health care system to have the newest medicines, procedures, and technologies. This study attempts to answer this important policy question. 

By comparing the United States (a non-universal system with multiple payers) to Britain (a universal, single payer system) and France (a universal multi-payer system), this study offers an opportunity to explore differences within and between these three varied health care systems.

The study divided the population of each city into income quartiles; for Manhattan and Paris monetary values were available while for London an indirect measure – the deprivation index – was used. Outcome measures associated with equity included mortality rates (subdivided by disease states), avoidable hospitalizations, specialist procedures such as breast reconstructions and joint replacements, and hospital discharges for certain conditions like broken hips and heart attacks (which should be unrelated to income under ideal circumstances).

Overall income inequalities were greatest in Manhattan and smallest in France.  Mortality and age-adjusted mortality rates in all three cities were statistically greater for the lowest income quartiles compared to the highest income quartiles. Disease-specific mortalities demonstrated a different pattern. Ratios greater than 1 indicate worse outcomes for lower income individuals. The ratio between lower and highest income quartiles for ischemic heart disease mortality was significant in Manhattan (1.34, p=0.001) and London (1.62, p=0.001) but not in Paris. The difference in diabetes mortality (ratio 4.01, p=0.001) was even more striking in Manhattan. In both Paris and London there was no significant difference. In neither city was breast cancer mortality difference across income quartiles. 

For all three cities, hospitalization rates were significantly greater for lower income quartiles. When classified by disease, hospitalization for hip fracture was not significantly different in either city. However, both London and Manhattan demonstrated higher hospitalization rates for heart attacks among lower income groups. For “avoidable” conditions, all three cities experienced marked differences in hospitalization rates. However, the disparity was greatest in Manhattan.

Access to specialty care was skewed towards higher income quartiles in London for cardiovascular services (p=0.01) and in Manhattan for joint replacements (p=0.01) and breast reconstructions (p=0.001). In Paris, these services were equally available to lower income and upper income quartiles.

In summary, Paris comes closer to achieving horizontal equity in health care than London or Manhattan.

 

Commentary

The French seem to have it right. Their multi-payer, universal health care system based on a philosophy of social solidarity achieves the greatest balance of equitable access to primary care and specialty care while permitting physicians to engage in private practice. Perhaps Congress, in its attempt to revamp the American health care system, should look to the French example. Although not perfect, perhaps America can adopt certain aspects of the French health care system just like Napa adopted wine-making and food-makers have adopted fries.

Journal of Health Politics, Policy and Law. 2009. 34 (4): 617-633.

 

by

Cedric K. Dark, MD, MPH

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