Health insurance markets and income inequality: findings from an international health policy survey

Abstract

Objective: To assess disparities in access to health care, financial burden of medical bills and perceived quality of care between those with above average incomes and those with below average incomes in five nations and to examine the relationship of inequities in care experi-ences to health insurance coverage. Design: Cross-sectional analysis of a random survey of adults in 1998. Subjects: 5059 adults ages 18 and over in five English-speaking countries: Australia, Britain, Canada, New Zealand and the United States (≈1000 per country) Main outcome measures: Failure to receive needed care, difficulty getting care, waiting time for elective surgery, problems paying medical bills, failure to fill prescriptions due to cost, perceived quality of medical care received and of most recent doctor visit. Results: There were two to three-fold differences between those with above and below average incomes on measures of access to care in the US, Australia and New Zealand. In Britain and Canada indicators of access to care were similar for the two income groups. Problems paying medical bills were most prevalent in the US, yet significant differences by income also existed in Australia, Canada and New Zealand. Those with below average incomes were more likely to have not filled a prescription due to cost in Australia, Canada, New Zealand and the US, with gaps by income most severe in the US. Ratings of quality of doctor visit were significantly different for the two income groups in the US, but not other countries. Conclusions: The analysis finds striking differences among countries in the relative equity of health care experiences. In general, care experiences are more unequal in three countries such as the US, Australia and New Zealand where systems have relatively greater reliance on private health insurance and markets. Greater inequality in care experiences is also associated with more divided public opinion regarding the need for system reform and the direction of recent policy changes. In Canada and Britain where care experiences are more equal, views of the health system are similar across income groups. Reliance on private insurance and patient user fees appears to lead to more divided views of the overall health system as well as inequity in access to care.

Introduction

Many studies have found disparities in use of health services by income class, with higher income individuals using more services than lower income individuals after adjusting for health status and morbidity [1], [2]. However, little is known about cross-national comparisons of equity in use or perceived access to health services. The comparisons that exist, rarely have the opportunity to use a common data-base and often must rely on different definitions and measures. Data that exist from past studies are frequently over 10 years old. In an era of rapid change in policy, budgetary constraints, or private market developments, it is therefore important to collect and analyze more recent data to reflect current conditions and examine the health system features that are associated with greater inequity in health services.

Industrialized countries vary widely in the extent to which public financing of health care and rules governing health care insurance markets seek to promote equity in health care experiences across income classes. Although the US stands out with its lack of universal coverage and emphasis on markets, among nations with universal public coverage, policies often differ regarding the role of private health insurance and market incentives created by patient cost-sharing. Differences in policies related to private health insurance, in particular, are likely to affect equity in care experiences — especially the extent to which lower income families’ access to care is protected and whether relatively affluent families can purchase a different standard of health care. To the extent that poliey results in health care experiences that vary markedly by income, market strategies are also likely to affect public views of the need for health care system reform.

This analysis of the 1998 Commonwealth Fund International Health Policy Survey examines how health care experiences and health system views vary by income class in five English speaking countries: Australia, Britain, Canada, New Zealand and the United States. In comparisons of the five countries, the analysis focuses on three central questions: How do access and cost experiences compare between below average and above average income families within each country? To what extent are variations in equity of experiences across the five countries associated with different policies regarding use of markets and private health insurance? What is the impact of income and equality of health care experiences on whether people perceive the need for system reform and the effect of recent policy changes?