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Health Care for the Wealthy or the Unhealthy?

Research shows that in Canada, health determines who sees a specialist, but in the U.S., income does.

Of all the myths out there about the Canadian health care system, perhaps the most popular is that sick people don't get the health care they need. The canards of the supposed inadequacy — long lines, government bureaucracy, insufficient doctors — are unfounded, but regardless, many Americans still balk at the prospect of socialized medicine that, they believe, won't heal the sick.

Academics David Feeney, Mark S. Kaplan and Bentson H. McFarland point out in an editorial in The Oregonian, that Canadians on average live almost three years longer than Americans - and they spend about half of what Americans do on health care.

Their research finds that in Canada, poor health predicts a visit to the specialist, while in the U.S., income does.

In the first U.S./Canadian study to compare socioeconomic and health status factors driving doctor visits, published in the January issue of the International Journal of Health Services, researchers found that elderly Americans in the top 40 percent of the income distribution were almost twice as likely as those in the bottom 20 percent to see a health care specialist. For Canadians, on the other hand, there was no statistically significant relationship between doctor visits and income: rather, poor health predicted specialist visits.

Lead author Kaplan, a professor of community health at Portland State University, says the findings are especially important in the context of national health care reform. In a university press release, he suggests that even with Medicare coverage, "some of the sickest Americans may not be able to afford the extra out-of-pocket expenses associated with seeing a specialist."

Earlier research confirms this: A 2007 working paper by the National Institute of Economic Research studied the effects of a policy change that raised patient cost-sharing for retired public employees in California. It found a connection between patient costs, physician office visits and prescription drug use, suggesting that how much elderly patients have to pay for health care does influence the treatment they seek. Ultimately, the paper recommends tying health insurance to underlying health status, with chronically ill patients responsible for a smaller proportion of health care costs.

The RAND Health Insurance Experiment, completed in 1982 (to date the only long-term study on cost sharing and its effects on health care use and health outcomes), also found that cost sharing caused participants (all of whom were under the age of 65 and therefore ineligible for Medicare) to use fewer health services than those participants receiving free care.

Feeney, Kaplan and McFarland, along with Natalie Huguet and Stacy S. Williams, analyzed data collected in a 2002/2003 survey by Statistics Canada, which included demographic, socioeconomic and health status information. The survey asked participants (755 elderly Canadians and 1,151 elderly Americans) if they had seen a doctor in the last 12 months. It also asked whether their most recent visit was to a general practitioner or a medical specialist.

In Canada, but not the United States, there was a strong association between poor health and specialist visits. Poor health was measured using the Health Utilities Index, a survey tool that asks participants to rate their health in eight categories, including vision, dexterity and pain. The lower that Canadian respondents rated their health, the more likely they were to have seen a specialist.

Approximately the same proportion of elderly persons in each country had seen some type of doctor in the previous year, but the U.S. respondents were significantly more likely to have seen a specialist for their most recent doctor visit than the Canadians. And in the U.S., respondents with household incomes of $50,000 or more (the top 40 percent of the income distribution) were almost twice as likely to have seen a specialist as those with incomes lower than $30,000 (the bottom 20 percent of the income distribution).

Feeney, an emeritus professor of economics at the University of Alberta, says the Canadian system is constructed to reduce financial barriers to access. In Canada, a private health care system that only covered 75 percent of the population was viewed collectively as insufficient. So the country voted for universal care.

"People who have higher incomes and are healthy are paying more and supporting those with lower incomes who are not healthy. It's an intergenerational social contract: When you're older and you may need more services, even though you're no longer paying the highest taxes, someone else who is younger and healthier than you pays into the system to benefit you, because they know that someone will do the same for them when they are older."

He argues that reducing administrative costs and negotiating lower prices for health care services are two steps that health care reform should take. He also believes in universal coverage without interruptions and health care based on need, rather than income.

"The U.S. spends much, much more per person per year, with marginally inferior outcomes. ... Canada spends much less on administration. For example, in Canada, there is only one set of insurance forms for everyone to fill out. Who gets covered? Everybody. What is covered? Everything that is deemed medically necessary. And there are no co-pays."

Feeney said he hopes his research with Kaplan and others will contribute to the body of evidence showing that it is possible to implement a system that responds to need and not income.

"It is an important result, and I hope it goes into the policy discussion. The current bill has important provisions that extend coverage to all Americans, regardless of pre-existing conditions. ... Obviously more reform will be needed, but if it passes, it will have a very profound effect on the insurance market, because the money companies will have to use to provide care for those people will have to come from somewhere. The health care system will have to be much more efficient in its allocation of resources."

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