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Socioeconomic Impact on Universal Care

Countries contemplating national health insurance cannot rely on universal health care to eliminate historical disparities in outcomes suffered by disadvantaged groups. Socioeconomic effects still plague nations such as Canada.

The inverse relationship between socioeconomic status and health disparities has been well documented.  It is common knowledge that individuals classified as low socioeconomic status have a higher propensity to chronic medical conditions that could be avoided if preventative care was accessible.  The passage of the Patient Protection and Affordable Care Act (PL 111-148) by the U.S. Congress in 2010 will extend coverage to approximately 32 million uninsured Americans by 2019.  Many proponents of the Affordable Care Act expect that an increase in health care accessibility will help combat the disparities often present in uninsured patients.  This goal, however, assumes that uninsured individuals will seek preventive and therapeutic care once health care has been made available.

This study focused on the types of health services used by a cohort of Canadians for over ten years prior to the onset of cardiovascular disease.  Canadian subjects were used in this study because barriers to health care access were eliminated with entitlement to publicly financed medical care devoid of co-payments and direct billing.  Participants’ health care-seeking behaviors were evaluated by the number of visits to a primary care physician that had billing codes identified as “preventive” services (proactive health care-seeking behavior) versus “other” services (responsive or reactive health care-seeking behavior).

The study consisted of 159,709 person-years of follow-up data received from the Ontario Health Survey, a subset of the 1996-1997 National Population Health Survey.  The participants had a mean age of 44.6 years (+/- 16 years) and were 54.3 percent women. Three categories were created to group the participants based on income and education levels (low, intermediate and high). A Mantel-Haenszel test was used to observe the differences in the participants’ characteristics across income and education categories.

Primary care visits among low income level patients averaged 62 visits compared to 47 visits among high income level patients (p<0.001), and 68.5 visits for low education level patients compared to 48.8 visits among high education level patients (p<0.001).  Although, there were an increased number of visits for the low income and education level patients, these visits were not for preventive care.  Both low education and income level patients developed diabetes and hypertension more often compared to the high education and income level patients.  High income and high education level patients also had lower morality risks (only 35 percent and 26 percent risk, respectively) compared to the low income and low education level patients.

The researchers concluded that patients of lower socioeconomic status made greater use of health services compared to patients of higher socioeconomic status, but it was secondary to disease progression.  Patients of lower socioeconomic status are likely to seek health care for acute/disease-reacting services instead of preventive services despite universal access to health care.

Commentary

The solution to health disparities for lower socioeconomic classes is a complex, daunting and urgent task for the nation’s health care community.  Universal health care, patient education, and proficient clinicians are important components needed to develop the solution.  Without accessible health care, lower socioeconomic patients most likely cannot afford any educational or informative preventive services delivered by the health care community.

Universal health care allows this at-risk group to utilize preventive servies.  As the study’s findings demonstrate, universal health care must not be the only change.

Developing effective and practical preventive services must be at the forefront of the American healthcare agenda.  These services should include mandatory annual exams and screening for at risk populations, as well as educational programs in areas such as nutrition, physical exercise, and mental health.  Finally, clinicians including physicians, nurses, and ancillary staff should receive focused training in preventive medicine to implement these new changes.

Alter, DA, et al. Lesson From Canada’s Universal Care: Socially Disadvantaged Patients Use More Health Services, Still Have Poorer Health. Health Affairs. 30 (2):274-283.

by

Tyree Winters, DO

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