Health insurance markets and income inequality: findings from an international health policy survey
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?
Section snippets
Methods and data
Data are from the 1998 Commonwealth Fund International Health Policy Survey, a five nation survey consisting of interviews with approximately 1000 adults age 18 and over in each of five countries: Australia (1001), Britain (1043 — all United Kingdom countries were included), Canada (1006), New Zealand (999), and the United States (1010). Interviews were conducted by Louis Harris and Associates Inc., and country subcontractors from April through June 1998 by telephone, except in Britain where
Country context: role of private health insurance and patient cost-sharing
Although the five study countries share a common language, they differ regarding the role of private insurance, patient out of pocket expenses and health care system financing. The US stands at one end of a spectrum with its strong reliance on a voluntary, private health insurance system and lack of universal health insurance. Working age adults (18–64) in the US tend to have either private health insurance provided voluntarily by employers, public coverage through Medicaid for low-income
Summary and discussion
The United States, with its absence of universal health insurance coverage and relatively greater role for both patient out-of-pocket spending and private market competition, has a highly inequitable health care system with generally large gaps in care experiences by income. The study found significant differences between below and above average income adults in the United States on six of seven measures of access to care (only waiting times for non-emergency surgery were not significantly
Discussion
The survey findings indicate that problems accessing health care for lower income populations can persist even in countries with universal health insurance coverage. Policies regarding the role of private health insurance and patient cost-sharing requirements are likely to matter. To the extent that those with private health insurance are able to avoid waiting lists or have more ready access to hospital and specialist care or avoid user fees, lower income families appear more likely to bear the
Acknowledgements
The Commonwealth Fund funded the survey and analysis. The views are those of the authors and not necessarily those of the directors, officers, or staff of The Commonwealth Fund or Harvard University. The authors would like to acknowledge Elisabeth Simantov, senior analyst for expert programming support and statistical analysis and Erin Strumpf, special assistant to the President for assistance in preparation of the final manuscript and tables. Both work at The Commonwealth Fund.
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