Advocates for Evidence-Based Health Policy Speakers
Equity in Health
A comparison of five countries reveals evidence of inequities in health for different income groups whenever cost sharing mechanisms are employed.
The concept of equity in health can be of diverse definitions depending on the perspective of the individuals involved. It can refer to horizontal equity – equal distribution of resources across all persons of equal need. It can refer to equity of outcomes and therefore represent disparities in health experienced by persons of various races, ethnicities, nationalities, incomes, or socioeconomic status classes. In this review from 2000, the Commonwealth Fund addresses equity between persons of differing economic situations by exploring several aspects of access to care and financial burden of health care. As an effort to explore the relationship of health system design on health equity, the authors compare randomly-selected individuals (nearly 1,000 in each) from 5 countries: the United States, Canada, Britain, New Zealand, Australia.
In this international comparison, the United States stands out as the only nation without a universal health care system. Among the others, mild variations exist. Both Australia and New Zealand have systems with a significant amount of cost-sharing mechanisms and supplemental private insurance. Canada and Britain have relatively few user fees but differ largely in the comprehensiveness of benefits. A major point of note is that Canada’s system does not cover prescription drugs in its public plan. In both Canada and Britain, private insurers are explicitly forbidden from selling services already included in the public plans.
Respondents were divided into “above average” and “below average” incomes groups based on self report. In all 5 countries, persons claiming to have above average incomes were more likely to have some form of private insurance. In the United States this disparity was approximately 2:1 (84 percent versus 42 percent). The effect was even more dramatic in Britain where although there is an approximately 4:1 difference (28 percent versus 7 percent), the overall prevalence of private insurance was a fraction of that of the U.S. system.
Large differences in difficulty accessing health care were apparent for all countries. However, only those with cost-sharing (that is, the United States, Australia, and New Zealand) demonstrated significant differences in perceived difficulty in access to care for persons of different financial means.
Respondents who did not fill a prescription as a result of cost were significantly more likely to be of below average income in the aforementioned 3 nations plus Canada. In Britain, where prescription drugs are included as part of national health insurance, no income disparity existed for this measure. Current estimates are that 1 in 5 Americans have not filled a prescriptions secondary to cost.
Financial burdens as a result of health care were similarly demonstrated for all nations again except Britain. For instance, in the United States 30 percent of individuals of below average income had difficulty paying medical bills compared to 9 percent of above average individuals. In Britain, these were 4 and 2 percent, respectively.
Another important findings is that people of below average income are more likely to feel that their respective health care system needs to be completely rebuilt compared to above average individuals. These differences in public opinion are significant for all countries except Britain. In the United States, 43 percent of people with below average income feel a complete overhaul of the health care system is necessary, compared to 26 percent of people with above average income.
Commentary
Although slightly out of date, this Commonwealth Fund survey provides empirical evidence about the possible benefits of universal health care systems in developed nations. As in the United States, with its largely privatized system, access to care for less affluent members of society declines whenever health care is delivered by private entities. In public systems, income disparities improve. It therefore appears that health care rationing occurs both explicitly and implicitly. Understanding this reality may diffuse some of the current opposition to a “public plan” in the current health reform debate.
by
Cedric K. Dark, MD, MPH