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

Abstract

PURPOSEUniversal coverage of physician services should serve to reduce socioeconomic disparities in care, but the degree to which a reduction occurs is unclear. We examined equity in use of physician services in Ontario, Canada, after controlling for health status using both self-reported and diagnosis-based measures. RESULTS After adjustment, higher education was not associated with at least 1 primary care visit (odds ratio [OR] = 1.05; 95% confi dence interval [CI], 0.87-1.24), but it was inversely associated with frequent visits (OR = 0.77; 95% CI, 0.65-0.88). Higher education was directly associated with at least 1 specialist visit (OR = 1.20; 95% CI, 1.07-1.34), with frequent specialist visits (OR = 1.21; 95% CI, 1.03-1.39), and with bypassing primary care to reach specialists (OR = 1.23, 95% CI 1.02-1.44). The largest inequities by education were found for dermatology and ophthalmology. Income was not independently associated with inequities in physician contact or frequency of visits. METHODS

Clinical Care and Health Disparities

“…In Scotland, lower-class individuals are equally likely to receive cardiac surgery if they are judged as equally urgent, but they are less likely to be judged as urgent (67). In Ontario, Canada, where there are disincentives for specialists to see patients without a referral from primary care, family income is unrelated to the seeking of care or frequency of visits to either primary care or specialists after controlling for morbidity burden (7,35). In the United States, black patients waiting for renal transplants are much less likely to receive them; patient characteristics, such as histocompatibility, account for only 14% of the inequity (38).…”

Is Individual Educational Level Related to End-of-Life Care Use? Results from a Nationwide Retrospective Cohort Study in Belgium

“…Both mechanisms are potentially influenced by the patient's educational attainment, partly via its mediator ''health literacy'' (defined as ''the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions''). [5][6][7][8][9][10][11] End-of-life care can be considered as a combination of general health care and (specialist) multidisciplinary palliative care, the latter skilled and experienced in specific aspects of health problems at the end of the life. Although socioeconomic inequalities in access to end-of-life care have been studied before, most studies have a limited scope (e.g., specific patient diagnosis group, small geographical areas), resulting in equivocal findings.…”

Unintended consequences of delisting routine eye exams on retinopathy screening for people with diabetes in Ontario, Canada

“…More research is needed to understand what proportion of diabetes eye examinations are paid for privately, whether disadvantaged residents of Ontario have decided to forgo these examinations entirely because of cost, and whether the decrease in screening was associated with an increase in retinal complications for people with diabetes. People with lower educational attainment are less likely to visit an ophthalmologist 20 and research is needed to understand whether delisting has exacerbated such inequities. In this time of fiscal restraint, policy-makers will increasingly debate which services are "medically necessary" and warrant coverage.…”