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Universal coverage may not eliminate health disparities

Even with everyone insured, poorer and less-educated patients experience worse outcomes, says a 10-year study of the Canadian health system.

By Kevin B. O’Reilly — Posted March 23, 2011

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The 32 million Americans expected to obtain insurance coverage by 2019 under the Patient Protection and Affordable Care Act are likely to have better access to health care. But if Canada's experience is any guide, disparities in health outcomes will continue.

Researchers followed 14,800 Canadian patients over 10 years and studied their use of health care services and health outcomes. Although all the patients were insured under Canada's single-payer health system, health outcomes varied by patients' income and educational levels, said a study in the February issue of Health Affairs.

"There is evidence out there that giving people who are uninsured some health insurance coverage will reduce disparities," said David A. Alter, MD, PhD, the study's lead author. "The word of caution is that will not eliminate disparities."

The high-income patients studied were 65% less likely to die during the 10-year study period than the low-income patients. Meanwhile, highly educated patients' mortality risk was 74% lower than that of less-educated Canadians. All patients were free of cardiac disease at the start of the study period.

Even after accounting for cardiovascular and other health, psychosocial and demographic risk factors, high-income patients still were 32% less likely to die than low-income Canadians. The best-educated patients had a 25% lower mortality risk than the least-educated patients, after risk adjustment. Researchers found no differences along racial or ethnic lines.

The low-income, low-education patients were more likely than their better-educated, well-to-do counterparts to see primary care physicians and specialists, but that is because they were sicker. Access to care did not encourage these patients to make better use of preventive services, eat healthier, exercise or quit smoking, said Dr. Alter, a senior scientist at the Institute for Clinical Evaluative Sciences in Ontario, Canada, and research director at the Toronto Rehabilitation Institute's Cardiac Rehabilitation and Secondary Prevention Program.

"Universal health care will not change behaviors," Dr. Alter said. "Some of this falls on the responsibility of patients."

Nations such as the U.S. that are broadening insurance coverage also should encourage preventive care and healthy lifestyles if they want to eliminate health disparities, he said.

The study is online (link).

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