Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health?

Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada.
Journal of Epidemiology & Community Health (Impact Factor: 3.5). 07/2003; 57(6):424-8. DOI: 10.1136/jech.57.6.424
Source: PubMed


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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    • "These are considered the most important determinants of access since people in ill health are generally more likely to interact with the health-care system (Andersen & Aday, 1978). The literature on access to care has traditionally focused on pre-disposing factors and need-based factors, while distinct attention has been paid to the role of socioeconomic status as an enabling factor in both publicly and privately funded health-care systems (e.g., van Doorslaer, Masseria, & Koolman, 2006; Veugelers & Yip, 2003). "
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    ABSTRACT: Research has shown persistent inequalities in access to health care between and within sociodemographic groups and geographic areas. Yet much of what we know about geographical disparities in access comes from studies of regional and urban/rural contrasts, or from studies of intra-urban, neighborhood-level variations. We know relatively little about variations in access to primary health care across different urban areas, and whether such variations translate into differences among residents’ health. This study examines how health status and access to primary care vary across five of Canada’s largest cities, paying particular attention to populations that may be particularly vulnerable based on age and income. Across all outcomes, there was a consistently strong relationship with individual socioeconomic status. We show that city of residence is important for access to health care but not for health status. Results are discussed in terms of their relevance for urban health-care policy and delivery, and impacts on health and access to care.
    Preview · Article · Nov 2014 · Urban Geography
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    • "This finding, consistent with other international research that shows low income is negatively associated with doctor contact [38,39], was evident despite the universal coverage of health services in Australia and the availability of free services for PWID. Countries with similar health systems see more primary care service use among lower socioeconomic groups [40,41], suggesting that there may be systematic differences between PWID and the general population that influence health service utilisation. In this health systems context, low income may be a marker of the impact of other issues such as the geographic access, cost of transport and competing priorities such as obtaining regular meals that we did not measure. "
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    ABSTRACT: Background People who inject drugs (PWID) use healthcare services, including primary care, at a disproportionately high rate. We investigated key correlates of general practitioner (GP) related service utilisation within a cohort of PWID. Methods Using baseline data from a cohort of 645 community-recruited PWID based in Melbourne, Victoria, we conducted a secondary analysis of associations between past month use of GP services unrelated to opioid substitution therapy (OST) and socio-demographic and drug use characteristics and self-reported health using multivariate logistic regression. Results Just under one-third (29%) of PWID had accessed GP services in the month prior to being surveyed. Participants who reported living with children (adjusted odds ratio, AOR 1.97, 95% CI 1.04 - 3.73) or having had contact with a social worker in the past month (AOR 1.92, 95% CI 1.24 - 2.98) were more likely to have seen a GP in the past month. Participants who were injecting daily or more frequently (AOR 0.50, 95% CI 0.30 - 0.83) or had a weekly income of less than $400 (AOR 0.59, 95% CI 0.38 - 0.91) were less likely to report having seen a GP in the past month. Conclusions Our sample frequently attended GP services for health needs unrelated to OST. Findings highlight both the characteristics of PWID accessing GP services and also those potentially missing out on primary care and preventive services.
    Full-text · Article · Jul 2014 · BMC Health Services Research
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    • "First instance, our recruitment from family-practices excluded individuals who did not visit a primary-care provider, perhaps due to socioeconomic reasons. Like all self-reported measures, reporting an arthritis diagnosis may reflect various non-clinical factors, such as the access to and utilization of health services needed to receive a professional opinion [46-48]. The relationship between SES, health perceptions and reporting behaviors may likewise bias our findings, although the direction and magnitude of these effects remain uncertain [49,50]; so far, two validation studies conducted by the CDC did not find significant differences in the sensitivity or specificity of the BRFSS self-reported arthritis according to education [51,52]. "
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    ABSTRACT: Associations of socioeconomic status (SES) with the prevalence of various forms of arthritis are well documented. Increasing evidence suggests that SES during childhood is a lasting determinant of health, but its association with the onset of arthritis remains unclear. Cross-sectional data on 1276 participants originated from 22 family practices in North-Carolina, USA. We created 4-level (high, medium, low, lowest) current SES and childhood SES summary scores based on parental and participant education, occupation and homeownership. We investigated associations of individual SES characteristics, summary scores and SES trajectories (e.g. high/low) with self-reported arthritis in logistic regression models progressively adjusted for race and gender, age, then BMI, and clustered by family practice. We found evidence for independent associations of both childhood and current SES with the reporting of arthritis across our models. In covariate-adjusted models simultaneously including current and childhood SES, compared with high SES participants in the lowest childhood SES category (OR = 1.39 [95%CI = 1.04, 1.85]) and those in the low (OR = 1.66 [95%CI = 1.14, 2.42]) and lowest (OR = 2.08 [95%CI = 1.16, 3.74]) categories of current SES had significantly greater odds of having self-reported arthritis. Current SES and childhood SES are both associated with the odds of reporting arthritis within this primary-care population, although the possibly superseding influence of existing circumstances must be noted. BMI was a likely mechanism in the association of childhood SES with arthritis onset, and research is needed to elucidate further pathways linking the socioeconomic environment across life-stages and the development of rheumatic diseases.
    Full-text · Article · Nov 2013 · BMC Musculoskeletal Disorders
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