Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health?
ABSTRACT Despite enormous public sector expenditures, the effectiveness of universal coverage for health care in reducing socioeconomic disparities in health has received little attention.
s: To evaluate whether universal coverage for health care reduces socioeconomic disparities in health.
Information on participants of the 1990 Nova Scotia Nutrition Survey was linked with eight years of administrative health services data and mortality. The authors first examined whether lower socioeconomic groups use more health services, as would be expected given their poorer health status. They then investigated to what extent differential use of health services modifies socioeconomic disparities in mortality. Finally, the authors evaluated health services use in the last years of life when health is poor regardless of a person's socioeconomic background.
The Canadian province of Nova Scotia, which provides universal health care coverage to all residents.
1816 non-institutionalised adults, aged 18-75 years, from a two stage cluster sample stratified by age, gender, and region. Main results: People with lower socioeconomic background used comparatively more family physician and hospital services, in such a way as to ameliorate the socioeconomic differences in mortality. In contrast, specialist services were comparatively underused by people in lower socioeconomic groups. In the last three years of life, use of specialist services was significantly higher in the highest income group.
Universal coverage of family physician and hospital services ameliorate the socioeconomic differences in mortality. However, specialist services are underused in lower socioeconomic groups, bearing the potential to widen the socioeconomic gap in health.
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ABSTRACT: The modern idea of health as a human right is examined, as it evolved from the 18th century, in terms of its origins, its essential content, and 20th-century attempts at implementation. Equity for social groups is seen as a guiding principle. Two attempts at implementation, in Britain and in Cuba, are examined for their effects on equity in health service and in health states. The British National Health Service achieved equity between social classes in services but failed to achieve it in health states (as measured by mortality). Deficiencies in commitment to public health services, it is argued, contributed largely to this failure. The Cuban experiment appears to have moved beyond equity solely in services and toward equity in health states. This success reflects an overall Cuban commitment to the public health. Two important elements of that commitment are, first, continuous evaluation with flexible response and, second, community involvement.American Journal of Public Health 04/1993; 83(3):418-26. · 3.93 Impact Factor
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ABSTRACT: This study examined whether socioeconomic status has a differential effect on the survival of adults diagnosed with cancer in Canada and the United States. The Ontario Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program provided a total of 58,202 and 76,055 population-based primary malignant cancer cases for Toronto, Ontario, and Detroit, Mich, respectively. Socioeconomic data for each person's residence at time of diagnosis were taken from population censuses. In the US cohort, there was a significant association between socioeconomic status and survival for 12 of the 15 most common cancer sites; in the Canadian cohort, there was no such association for 12 of the 15 sites. Among residents of low-income areas, persons in Toronto experienced a survival advantage for 13 of 15 cancer sites at 1- and 5-year follow-up. No such between-country differentials were observed in the middle- or high-income groups. The consistent pattern of a survival advantage in Canada observed across various cancer sites and follow-up periods suggests that Canada's more equitable access to preventive and therapeutic health care services is responsible for the difference.American Journal of Public Health 08/1997; 87(7):1156-63. · 3.93 Impact Factor
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ABSTRACT: Investigations of contextual factors (income inequality, cultural disruption, access to health and social services, safety and crime rate, and others) have received little emphasis by epidemiologists, although a few have demonstrated the importance of such factors for mortality, particularly in the United States. To expand current understanding of the importance of contextual factors, the authors evaluated mortality in a longitudinal study in Nova Scotia, Canada, where all residents have greater access to health and social services and where income inequalities are smaller than in the United States. A total of 2,116 participants were followed from 1990 through December 1999, linked to the 1991 Canada Census as a source of neighborhood characteristics, and analyzed using individual-level and multilevel logistic regression. Well-educated and high-earning persons fared better. Neighborhood socioeconomic characteristics (neighborhood income, educational level, unemployment rate), in contrast, were not significantly associated with mortality. However, within advantaged neighborhoods, the importance of individual income and education for mortality was increased relative to disadvantaged neighborhoods. The latter findings may direct health policy aimed at reducing health inequalities.American Journal of Epidemiology 11/2001; 154(8):725-32. · 4.78 Impact Factor
PUBLIC HEALTH POLICY AND PRACTICE
Socioeconomic disparities in health care use: Does
universal coverage reduce inequalities in health?
P J Veugelers, A M Yip
J Epidemiol Community Health 2003;57:424–428
Background: Despite enormous public sector expenditures, the effectiveness of universal coverage for
health care in reducing socioeconomic disparities in health has received little attention.
Study objectives: To evaluate whether universal coverage for health care reduces socioeconomic dis-
parities in health.
Design: Information on participants of the 1990 Nova Scotia Nutrition Survey was linked with eight
years of administrative health services data and mortality. The authors first examined whether lower
socioeconomic groups use more health services, as would be expected given their poorer health status.
They then investigated to what extent differential use of health services modifies socioeconomic dispari-
ties in mortality. Finally, the authors evaluated health services use in the last years of life when health
is poor regardless of a person’s socioeconomic background.
Setting: The Canadian province of Nova Scotia, which provides universal health care coverage to all
Participants: 1816 non-institutionalised adults, aged 18–75 years, from a two stage cluster sample
stratified by age, gender, and region.
Main results: People with lower socioeconomic background used comparatively more family
physician and hospital services, in such a way as to ameliorate the socioeconomic differences in mor-
tality. In contrast, specialist services were comparatively underused by people in lower socioeconomic
groups. In the last three years of life, use of specialist services was significantly higher in the highest
Conclusions: Universal coverage of family physician and hospital services ameliorate the
socioeconomic differences in mortality. However, specialist services are underused in lower socioeco-
nomic groups, bearing the potential to widen the socioeconomic gap in health.
mented across and within many countries. Various mecha-
nisms for this socioeconomic gradient in health have been
proposed.1–5Poor lifestyle habits such as smoking, poor diet,
and physical inactivity are more prevalent in lower socioeco-
nomic groups.2 6–8Similarly, the propensity to use preventive
health services,such as regular medical check ups and partici-
pation in population screening programmes,is more prevalent
among higher socioeconomic groups.1 6 7In addition, financial
and otherbarriers to health services may perpetuate orfurther
augment existing socioeconomic disparities in health.5 9The
inability of lower socioeconomic groups to purchase costly
health services or insurance may prevent them from accessing
care. This poses an important disadvantage for these groups,
given their greater burden of disease and corresponding
greater need for health services.10–15
Publicly funded health care aims to deliver services on the
basis of need rather than ability to pay, thus overcoming
financial barriers to access and reducing inequity. Most devel-
oped countries provide some coverage of basic health services
for segments of their populations.The extent and comprehen-
siveness of coverage, however, vary substantially among
countries.16In Canada, public health insurance evolved over
the second half of the 20th century such that by the early
1970s, all provinces and territories provided universal
coverage for hospital and physician services. In the context of
an aging population and ever increasing health spending17—
total public sector health expenditures for all the Canadian
provinces and territories combined were estimated to reach
$74 465 billion (53.68 billion euros) in 2001, about 9.3% of
socioeconomic gradient in health, whereby wealthier,
more highly educated persons experience better health
than poorer, less educated persons, has been well docu-
gross domestic product18—it is important to evaluate whether
this financial burden indeed results in a reduction in
socioeconomic health inequalities. The existing literature in
this area generally consists of studies comparing the situation
before and after the introduction of a universal health insur-
ance programme. The US introduction of Medicare and Med-
icaid for certain segments of the population demonstrated
that the resulting improved access to care substantially
reduced disparities in health care utilisation6;however,gaps in
coverage and in overall health status remain.19 20Similarly,
despite the introduction of the National Health Service in the
UK, socioeconomic gradients in health and mortality have
persisted.21 22InCanada,a1991review ofresearchcoveringthe
first two decades of Medicare concluded that the introduction
of national health insurance had succeeded in providing a
common entry point to the system by removing the basic bar-
rier of out of pocket payment; however, socioeconomic
disparities in the amount and type of care utilised and
ultimately in health status remained.12More recent evalua-
tions are no longer based on comparisons with the situation
before the introduction of Medicare and, instead, have often
used the US as a comparison group.For example,comparisons
of physician and hospital use in the Canadian province of
Ontario and the US have suggested that Canada’s single payer
system has been successful in redistributing services to those
with the most need, namely lower income people.13 14Also,
comparisons of cancer survival in Canadian and US cities
found that Canadians fared better, especially in lower
socioeconomic groups.23–25Canada and the US differ in numer-
ous ways,5 20 26and thus the observed differences in health
cannot solely be attributed to the differences in health care
coverage. Additional studies are needed to investigate the
See end of article for
Dr P J Veugelers,
Department of Community
Health and Epidemiology,
Faculty of Medicine,
Dalhousie University, 5849
University Avenue, Halifax,
Nova Scotia, Canada B3H
Accepted for publication
8 September 2002
adequacy of universal coverage in reducing socioeconomic
In this study, we use three approaches to evaluate whether
universal coverage for health care reduces socioeconomic dis-
parities in health.Firstly,we evaluate whether lower socioeco-
nomic groups use more health services, as would be expected
given their poorer health status. However, even if their use of
health services is higher, this may still be inadequate to meet
their greater needs and may potentially contribute to further
inequalities in health. Therefore, in our second approach we
evaluate to what extent the use of health services affects
socioeconomic disparities in mortality. In the last years of life,
health is poor and health care use is heavy,regardless of a per-
son’s socioeconomic background. In the absence of barriers to
health care, it would be assumed that the demand for health
services is similar across socioeconomic groups. As a third
approach, we examine differential health care use by
socioeconomic status in the last years of life.
Study design and health measures
This study used data on participants of the Nova Scotia Nutri-
tion Survey, linked with information on subsequent use of
health services and vital statistics.5 9 27The survey was held in
1990 and consisted of 2198 non-institutionalised residents of
the Canadian province of Nova Scotia, aged 18–75 years, from
a two stage cluster sample stratified by age, gender, and
region.Survey information of 82 participants (3.8%) could not
be linked with provincial health care databases and vital sta-
tistics and thus were not included in the analyses. The
remaining 2116 survey participants were categorised into
socioeconomic strata on the basis of their household income
(less than $20 000; $20 000 to $39 999; and $40 000 or more).
As the question on income was elective, this information was
not available for 300 participants (13.6%). Analyses were
therefore restricted to the remaining 1816 participants. Infor-
mation on health care use included the number of family
physician services, specialist services, and days in hospital
during the eight years afer the interview. During these eight
years, 79 (4.4 %) participants migrated out of Nova Scotia
while 149 (8.2%) died; their observations, until the date of
departure or death, were included in the analyses. The
database linkages used in this study were approved by the
Health Sciences Human Research Ethics Board of Dalhousie
University, Halifax, Nova Scotia, Canada.
We compared characteristics and health outcomes of survey
analyses using χ2, median, and t tests.
We evaluated whether public health care reduces socioeco-
nomic disparities in health in three different ways. Firstly, we
described health care use (family physician services,specialist
services, and days in hospital) for each of the socioeconomic
strata during the eight years of follow up. As the distributions
of health services use are highly skewed, we calculated the
median number of health services in each stratum. In
addition, we dichotomised health services use into low and
heavy categories,using the median as a cut off,and calculated
age and gender adjusted odds ratios of low compared with
heavy health services use across socioeconomic strata using
Secondly, we evaluated the interrelations between health
services use,socioeconomic background,and mortality during
the eight years of study. We quantified socioeconomic
differences in mortality in terms of age adjusted and gender
adjusted odds ratios using logistic regression. When these
odds ratios are further adjusted for health services use, the
new odds ratios will be closer to unity if health services are
used comparatively more by people of lower socioeconomic
background and with comparatively poor health. In contrast,
the adjustment for health services use will result in diverging
odds ratios if people of lower socioeconomic background and
with poor health use comparatively fewer health services. We
present age and gender adjusted odds ratios for mortality by
income category and odds ratios further adjusted for use of
family physician and specialist services and days in hospital.
Characteristics of participants of the Nova Scotia Nutrition Survey
missing) (n=300) p value†
Mean age in years (SD)
Body mass index (%)
20 to <27
Household income (%)
$20000 to <$40000
Less than high school
High school, trade/vocational training
Family physician services
Median annual services (IQ range)
Specialist physician services
Median annual services (IQ range)
Hospital services – any use (%)
49.2 (15.3)34.8 (15.5)<0.01 50.5 (17.4)0.25
0.52 186 (62.0)
12 (14.6)300 (100.0)
<0.01 157 (52.3)
4.75 (6.38)– 5.07 (5.25)0.19
SD, standard deviation; IQ, range: interquartile range. *Probability that participants excluded because no linkage could be established do not differ from
included participants. †Probability that participants excluded because of missing income do not differ from included participants. ‡Where the cell count
<5, we apply Fisher’s exact test.
Socioeconomic disparities in health care use425
In a third analytical approach, we investigated health serv-
ices use in the last years of life assuming that health in these
years is poor regardless of socioeconomic background. For
those who died during follow up,we described health services
use (family physician services, specialist services, and days in
hospital) during the three years preceding death for each of
the socioeconomic strata. Here we also dealt with skewed dis-
tributions by using median values and calculating odds ratios
that characterised the socioeconomic variation in low (below
median) and heavy (above median) health services use.
We followed published guidelines28for the longitudinal
analysis of surveys with stratified sampling, which recom-
mend adjusting for all variables used in defining sample
weights (age, sex, and region), without incorporating these
weights.As region did not substantially affect our estimates of
interest,we retained only age and sex as covariates.Data were
analysed using S-PLUS 2000 software.
Table 1 presents the characteristics and health outcomes of the
1816 participants with complete information in comparison
with the 82 (3.8%) that were excluded because of missing
linkable identifiers, and with the 300 (13.6%) that were
excluded because of missing information on household
income. The 82 for whom data linkage could not be
established were substantially younger and from a higher
income and better educated background. This clearly repre-
sents a young prosperous subgroup including students whose
high mobility hampered linkages.The 300 with missing infor-
mation on income were more likely to be female, non-
smokers, and less educated, but did not substantially differ
from included participants with respect to health services use.
Figure 1 provides an initial visualisation of the distribution
of health services use by income group. Participants who
reported a household income of less than $20 000 constituted
31% of the study population and used disproportionately more
health services; of all services delivered to this study
population, the low income group used 43% of the family
physician services, 38% of the specialist services, and 50% of
the days in hospital. Participants with a household income of
more than $40 000 constituted 29% of the study population
and used 21% of the family physician services,26% of the spe-
cialist services, and 13% of the days in hospital. This figure
should be interpreted with caution,as differences are not con-
trolled for the effects of age and gender. Table 2 presents the
age and gender adjusted odds ratios for health services use by
income group. Participants with an income of more than
$40 000 were about half as likely (odds ratio =0.51) to be
heavy users of family physician services than those with an
income of less than $20 000. These differences were statisti-
cally significant. Variation in specialist services use across
income groups was substantially less; all income groups had
comparatively even distributions of heavy versus low users.
With respect to hospital use,figures similar to those for family
physician use were obtained; participants with higher income
had fewer days in hospital than those in the lower income
groups. These differences were also statistically significant.
Table 3 shows the differences in mortality by income group.
The odds ratios adjusted for age and gender indicate lower
mortality with increasing income (odds ratios of 0.79 and 0.56
for middle and high income groups respectively). These
differences were attenuated by accounting for level of family
physician services used (odds ratios of 0.90 and 0.68).
Although the differences are not statistically significant, the
attenuation suggests that family physician services were used
more heavily by individuals with lower income and poorer
health. Based on the premise that health services benefit
Differences in health services use by income among participants of the Nova Scotia Nutrition Survey
Family physician services Specialist servicesDays in hospital
N OR95% CINOR95% CINOR95% CI
0.52 to 0.83
0.39 to 0.66
0.81 to 1.30
0.74 to 1.25
0.49 to 0.79
0.45 to 0.75
N, Median annual number of family physician services, specialist services, or days of hospitalisation; OR, odds ratio adjusted for age and gender
differences; 95% CI, 95% confidence intervals of odds ratio.
Distribution of study participants and health services use
Mortality differentials by income and health services use among participants of the Nova Scotia Nutrition
participantsOR 95% CI
Family physician services Specialist servicesDays in hospital
OR95% CIOR 95% CIOR 95% CI
0.52 to 1.19
0.31 to 1.02
0.58 to 1.41
0.36 to 1.26
0.45 to 1.10
0.17 to 0.66
0.50 to 1.34
0.34 to 1.27
OR, odds ratio are all adjusted for age and gender differences and, in the corresponding columns, further adjusted for family physician services, specialist
services, or days in hospital; 95% CI, 95% confidence intervals.
426 Veugelers, Yip
health, these figures also indicate that family physician serv-
ices reduced income disparities in mortality. Adjusting for
specialist services use (odds ratios of 0.70 and 0.33)
augmented the variation in mortality, indicating that special-
ist care did not contribute to a reduction in socioeconomic
disparities.Accounting for days in hospital had an attenuating
effect on income differences in mortality (odds ratios of 0.82
and 0.66) similar to the effect of family physician services.
Table 4 presents results of analyses similar to table 2 but
only for the 149 participants who died during follow up. As
would be expected, the level of health services use was much
higher in the last years of life than in the general population
(comparing median values presented in table 4 versus table 2).
There was some variation in level of family physician services
and hospital days used by income group, although not statis-
tically significant.In contrast,specialist services use in the last
years of life was significantly higher in the highest income
Lower socioeconomic groups experience poorer health status
and have higher health care needs. This study shows that
people with lower socioeconomic background and with poor
health used comparatively more family physician and hospital
services and in such a way as to ameliorate the socioeconomic
differences in mortality. In contrast, specialist services were
comparatively less used by people with lower socioeconomic
background and with poor health; this underuse bears the
potential to widen the socioeconomic gap in health.
Ecological comparisons of neighbourhoods within the
Canadian cities of Winnipeg and Toronto demonstrated
greater use of health services in lower income neighbourhoods
relative to more affluent neighbourhoods.29 30Similar trends
were observed among people participating in the Canadian
National Population Health Survey31and in this study. Clearly,
the poorer health of lower socioeconomic groups drives their
increased use of health services,and universal coverage allows
this to happen. To investigate whether this increased use of
health services in lower socioeconomic groups is sufficient to
meet their greater needs, researchers have quantified health
services use while adjusting for socioeconomic differences in
health care needs. In this respect, they have used self rated
health and self reported health problems as proxies for health
care need.Using such proxies,Dunlop et al32found that people
of lower socioeconomic background consulted their family
physician more frequently even if their higher needs for health
services were controlled for. Specialist services, in contrast,
were more frequently reported in higher income groups.32
With respect to hospital care,Newbold et al33found no statisti-
cal differences among socioeconomic groups when differences
in need for health services were controlled for. These findings
are in agreement with our observations of health services use
in the last three years of life, during which we assumed that
need for health services was high regardless of a person’s
socioeconomic background. The studies by Dunlop et al and
Newbold et al used self reported health services use based on
national cross sectional surveys, whereas we conducted longi-
tudinal analysis based on eight years of administrative health
services data within the province of Nova Scotia. Also, the ref-
erenced studies considered need for health services use that
was proxied by self rated health and self reported health
problems, whereas we considered mortality during the eight
years of follow up as a health outcome. The differing designs
and populations of the above studies strengthen the mutual
concern that specialist services do not equitably reach lower
socioeconomic groups despite the existence of universal
coverage. Furthermore, this study adds to the above findings
by demonstrating that differential use of specialist services
bears the potential to widen the socioeconomic gap in health,
whereas family physician and hospital services are demon-
strated to ameliorate the socioeconomic differences in
The increased use of family physician and hospital services
in lower socioeconomic groups seems to correspond to their
higher need resulting from their poorer health. This mech-
anism may contribute to the attenuation of the socioeconomic
gradient in health. An example; hypertension is more
prevalent in lower socioeconomic groups (A M Yip, et al, XVI
IEA World Congress of Epidemiology, Montreal, QC, 18–22
August 2002). Family physician practice to control hyper-
tension will reduce the cardiovascular risk burden that will
particularly benefit the health of lower socioeconomic groups,
thus contributing to the amelioration of the socioeconomic
gradient in health.This study also showed that specialist serv-
ices were comparatively less used in lower socioeconomic
groups, while their need is again expected to be higher. This
lower use of specialist services may be a result of differential
referral to specialist services, as reported previously.7 29 32 34
The high location rate (75%) and response rate (79%) of the
Nova Scotia Nutrition Survey should be considered as an
additional strength of this study. However, the exclusion of
3.8% of participants without linkable identifiers and 13.6%
without income information should be acknowledged as a
limitation affecting the generalisability of the present results.
Differences in health services use in the three years before death among participants of the Nova Scotia
Family physician servicesSpecialist servicesDays in hospital
NOR95% CINOR95% CINOR 95% CI
0.54 to 2.31
0.11 to 1.14
0.52 to 2.22
1.35 to 16.22
0.58 to 2.49
0.43 to 2.00
N, Median number of annual family physician services, specialist services or days of hospitalisation; OR, odds ratio adjusted for age and gender
differences; 95% CI, 95% confidence intervals of odds ratio.
• Universal coverage of family physician and hospital
services ameliorates the socioeconomic differences in mor-
• Despite universal coverage of specialist services, these
services are underused in lower socioeconomic groups,
bearing the potential to widen the socioeconomic gap in
• Universal coverage of health care can be an effective
means to reduce socioeconomic disparities in health.
• Identification of underused specialist services is important to
facilitate health policy and targeted interventions aimed at
further reduction of socioeconomic disparities in health.
Socioeconomic disparities in health care use 427
Despite the exclusion of these participants, the sample size of
1816 participants seemed effective to reveal statistically
significant associations between income groups with respect
to health services (table 2). However, the sample size was
insufficient to reveal statistically significant income differ-
ences in mortality and the extent to which income differences
change when considering health services (table 3). This limi-
tation urges confirmation of these findings by research in
countries that provide universal coverage to their residents.
Also, contrasting findings in countries with and without uni-
versal coverage are indicative of their effectiveness in
socioeconomic disparities in health.
In conclusion, the expenditures for health care are
enormous and likely to increase further in light of the aging
population in most developed countries. The effectiveness of
these expenditures in reducing socioeconomic health dispari-
ties has received comparatively little attention. As health care
coverage is universal and hence the assessment of effective-
ness is hampered by the absence of a comparison group, our
understanding to date comes primarily from comparisons of
the situation before and after the introduction of universal
coverage and from comparisons of countries with and without
universal coverage. As these comparisons all have limitations,
the importance of new approaches to demonstrate effective-
ness, such as this study, become apparent. These findings add
new knowledge in that universal coverage of family physician
and hospital services ameliorates the socioeconomic mortality
by lower socioeconomic groups and may contribute to widen-
ing this socioeconomic gap. Further research into the mecha-
nisms and types of specialist services involved is important to
facilitate health policy and targeted interventions aimed at
further reduction of socioeconomic disparities in health.
The authors thank Angela Fitzgerald, Shane Hornibrook, George
Kephart, Michael Pennock, Chris Skedgel, and Mark Smith for their
helpful assistance. Parts of this research were presented at the
Congress of Epidemiology 2001, Toronto, Canada, 13–16 June 2001.
P J Veugelers, A M Yip, Department of Community Health and
Epidemiology, Faculty of Medicine, Dalhousie University, Halifax,
Funding: support for this study is provided through funding by the
Canada Foundation for Innovation, the Dalhousie Medical Research
Foundation, the Nova Scotia Health Research Foundation and a
Canadian Institutes of Health Research Career Award to Dr Veugelers.
Conflicts of interest: none.
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