INEQUALITIES IN PRIVATE AND PUBLIC HEALTH SYSTEMS: THE
UNITED STATES, FRANCE, CANADA AND GREAT BRITAIN
|Victor G. Rodwin|
New York University
Over fifteen years ago, in a comparative study of the United States,
Sweden and England, Odin Anderson characterized the quest for greater
equity in health as an "endless search for the dream."1 The validity of
this statement depends not only upon empirical evidence, but also upon
one's concept of equity. It will be argued here that it is possible to
attain what may be called a "weak concept" of equity. The search for what
may be termed a "stronger concept" of equity, however, so far has proved
elusive - at least in the United States, France, Canada and Great Britain.|
Inequalities in health - both in relation to outcomes (health status) and to
the availability and use of medical care - have been studied quite thoroughly.2
There is extensive work on alternative concepts of equity,3 and there is a
large number of empirical studies which document inequalities in health
status and measure access to medical care in relation to various concepts
of equity.4 One gap in this literature, however, is the absence of a standard
of comparison by which to assess the extent of health inequalities in the United States.|
This chapter will attempt to assess the extent of health care inequalities in
the United States as compared to the situation in other, more "public" health
care systems. it is not possible to make systematic comparisons because each
country relies on different categories in defining such concepts as socioeconomic
status and health status. Nevertheless, since the comparative approach is not
well developed, it is possible to make a modest contribution in this
The initial presumption was that problems of inequality are more severe in
the relatively private, market-based health care system of the United States
than in the more publicly controlled systems with a national health service,
such as in Great Britain, or with national health insurance, such as in Canada
and France. This turns out to be true when grounded in the weak concept of
equity. However, regarding a stronger concept of equity, the evidence suggests
that inequalities are pervasive in all of these systems.|
|On the Concept of Equity in Health Care|
Enough able minds have addressed the concept of equity in health care
so as to make all but the most ignorant or courageous analysts hesitate
to take on the subject anew.6 For purposes of this discussion, it is
sufficient to begin with three well-known distinctions: first, between
equity and equality; second, between equity in levels of health or health
care and equity in financing; and third, between the weak and the stronger
concepts of equity - both of which will be relied upon to interpret the
empirical evidence presented subsequently.|
Equality means "the same" in the sense that George Orwell played with the
concept in Animal Farm.7 Many would probably support the ideal of promoting
measures to make health status equal among all. For example, there should be
no strong objections to making life expectancy between the sexes, or even
between social classes, equal. Few, however, would expect such efforts to
succeed given the differences among groups and individuals in their genetic
makeup, income and educational levels. No one, not even the most fanciful
utopian, would presume that the use of health care services should be equal
among individuals. People who are sick should receive more medical care
services than those who are well. How much more they should receive is
not merely a technical issue. To the extent that this question raises
issues of social justice, it becomes an issue of equity.|
The second distinction, between equity in levels of health or health care
and equity in financing, involves the interrelationships between costs and
benefits. Attitudes and perspectives, of patients, providers and/or taxpayers,
often vary. From the point of view of financing, it is crucial to distinguish
the distribution of costs between those who actually receive services and the
larger set of all who pay for them.8 But this discussion is concerned only
with equity in achieving levels of health and in receiving health care services.|
A weak concept of equity in health care would suggest that everyone is entitled
to, and actually receives upon request, a basic minimum of health care services.
Norman Daniels associates this concept with the presuppositions about equity
which underlie Alain Enthoven's Consumer Choice Health Plan for national health
insurance in the United States.9 Such a notion also resembles the view advocated
by the President's Commission for the Study of Ethical Problems in Medicine,
which concluded that equitable access "requires that all citizens be able to
secure an adequate level of care without excessive burdens.10|
A stronger concept of equity presupposes far more ambitious aims. For example,
in the best of all possible worlds, one might wish that despite severe
inequalities in income and wealth, an ideal health care system would
somehow provide sufficient remedial effects so as to make death (mortality)
and disease (morbidity) independent of an individual's socioeconomic status.
Likewise, one might want the use of services by consumers and the diagnostic
procedures and therapeutic treatment provided by health care professionals
(and even the manner in which these are provided) to be related only to the
patient's medical condition, not to his or her ability to pay. Such a concept
of equity assumes an equitable distribution of health care services - "one in
which illness is the major determinant of the allocation of resources.11|
Both the weak and the stronger concept of equity in health care can be applied
to outcomes (health status) as well as to inputs (use of health care resources).
The weak concept of equity justifies a range of inequalities based on differences
in income and preference. The stronger definition, however, suggests that with
respect to health status, equally situated individuals should be treated equally
(horizontal equity) and unequally situated individuals should be treated
unequally (vertical equity). Also, the stronger equity concept suggests
that there should be equal access to health care services, i.e., that the
ways in which patients differ in their geographic residence or socioeconomic
status should not lead to systematic differences in their use of services or treatment.|
Both concepts of equity mirror a set of values; both will be used as criteria by
which to evaluate the health care systems in the United States, France, Canada
and Great Britain. After distinguishing between public and private health care
systems and classifying health systems along a public/private continuum, the
nature of health inequalities in these systems from the perspective of the
weak and the stronger concepts of equity will be assessed.|
|Public Versus Private health Systems|
Health care systems vary in the public/private mix of their financing
and organization.12 The United States, for example, is known to differ from
Canada and Western Europe because it is at the private end of the public/private
spectrum.13 In comparison to France, Canada and Great Britain, the United States
is the highest health care spender (public and private combined), but it has the
lowest share of public expenditures on health as a percentage of its gross domestic
product (GDP). (See Table 1.) As to sources of financing, the United States health
system relies the most on direct consumer payments and private health insurance,
and the least on public insurance and government revenues. The United States has
the most "private" system in still another respect, for it spends the smallest
share of health expenditures in government-administered institutions.|
At the opposite extreme, Great Britain is the lowest health care spender (public
and private combined), yet it retains a relatively high share of public expenditures
on health care as a percentage of GDP. Great Britain also has the smallest role for
direct consumer payments and, in spite of recent growth, a very small private health
insurance industry.14 Direct government financing plays the largest role. In terms
of organizational structure, Great Britain is the most "public" system: it is,
after all, a national health service (NHS).|
France and Canada represent two models of national health insurance (NIH). Both fall
midway between the extremes of the United States and Great Britain. Canadian NH! is
financed largely by government revenues, and health services are provided, for the
most part, in private, fee-for-service practices and private, not-for-profit
hospitals. French NHI, by contrast, is financed largely by social security
payroll taxes, and health services are provided in private, fee-for-service
practices and in a mix of public and private, for-profit hospitals, which is
dominated largely by the public ones. In contrast to France, Canada and Great
Britain, the United States is the only industrially advanced nation that lacks
a system of compulsory and universal entitlement to health insurance. As a
consequence, roughly 15 percent of the population is uninsured for health care
France established a system of Nil! covering all industrial workers in 1928.
In a spirit of solidarity, the system was extended to all salaried workers following
World War II, followed by agricultural workers in 1961 and the self-employed in 1975.
By 1978, virtually all of the population was covered under a compulsory universal NH!
scheme.16 Benefits include the services of general practitioners and specialists
in office-based practices as well as in hospitals, laboratory tests and diagnostic
procedures, prescription drugs, dental services, coverage for work accidents, sick
days, and maternity leave and care. Beneficiaries are reimbursed substantially,
but not in full. Although there are no deductibles, patients must contribute a
small copayment for each day spent in a hospital and a coinsurance payment
allowable for outpatient services-roughly 20 percent of the negotiated fee.
Approximately onefourth of French physicians have opted to engage in "extra-billing,"
which drives up the level of coinsurance beyond 20 percent.|
Canada passed federal legislation which encouraged its provincial governments to
adopt hospital insurance in 1957 and insurance for medical care (outside the hospital)
in 1966. By 1970, all Canadian provinces had established a system of health insurance
which provided universal coverage for Canadian residents and a comprehensive benefit
package comparable to that provided in France, with the exception of prescription
drugs.17 In France, coverage for drugs is far broader than Canada, but Canadian NHI
provides first-dollar coverage: there are neither deductibles nor out-of-pocket
copayments for patients. What is more, in contrast to France, extra-billing is more
restricted and patients are not required to advance payment for ambulatory care and
then wait for reimbursement. Providers are reimbursed directly by the provincially-controlled
health insurance funds.|
The British NHS was enacted in 1946 and established in 1948. The 1944 white paper
preceding its enactment proclaimed that "everybody in the country should have an
equal opportunity to benefit from medical and allied services."18 Thus, the NHS
entitles all British subjects and legal residents to receive "needed" medical care
free of charge at the point of consumption. The health system is organized as a
tripartite structure. Hospital care is provided within districts which receive
budgets from regional health authorities. General practitioner services, as well as
dental and ophthalmic services, are organized by family practitioner committees who
contract with these professionals to take responsibility for providing services to a
designated population. Finally, public health services and certain categories of home
care and social services are provided by local authorities. The system is almost
entirely financed through general revenue taxation, and the physicians and hospitals
must meet the demand for health care services within clearly defined budgetary constraints.|
|The Weak Equity Criterion|
According to this criterion, all citizens should be able to secure a basic minimum
of health care services or, to reiterate the expression used by
the President's Commission, an "adequate level of care without excessive burdens.19
The United States is the only country in this comparison that fails to pass this test.
In France, Canada and Great Britain, the entire population is entitled to use medical
care services. There is no category equivalent to the American term "uninsured."
There are occasionally coinsurance requirements in France and occasional copayments
in Great Britain, such as for drugs. Occasionally there are problems in obtaining
access to more specialized services in France, Canada and Great Britain, but such
problems are systematic only in the latter where rationing of certain specialized
services such as kidney dialysis is standard practice.20 Furthermore, there are never
any financial barriers to receiving primary care services (on both an outpatient and an
inpatient basis) in the three countries, and one would be hard pressed to find examples
of hospitals "dumping" patients to other facilities on financial grounds.21|
Of course, it is difficult to define what constitutes an "adequate level of care."
Given some definitions, it is entirely possible-even probable-that France, Canada
and Great Britain do not provide adequate levels of care to certain segments of
their populations. But only the United States has a health care system in which
a significant portion of the population is uninsured and, because of this status,
contains systematic differences in patterns of medical care use. What is more,
only the United States has experienced a recent trend where the percentage of the
uninsured has been rising, and the gap in patterns of medical care use between the
insured and the uninsured has been widening.|
These characteristics disclose the existence of a two-tiered health care system in
which the adequacy of the care provided for the bottom tier appears to be eroding.
The argument that the United States fails to meet the weak equity criterion rests
on the proposition that the uninsured, a lower tier in the American health system,
receive less than an adequate level of care. A less than adequate level of health care
in this context is a relative judgment: first, in relation to the level of care
received by those in the higher tier; and second, to the level of care received
by the lower tier over time. On both grounds, recent studies in the United States
suggest that the uninsured are receiving less than an adequate level of health care
In a comparison of health services received by the uninsured with those received by
the publicly insured (under Medicaid), Robert Biendon and his colleagues have shown
that the level of care is significantly different.22 Their survey data (collected
before Arizona became the only state with no Medicaid program) indicated that
low-income people received substantially less medical care from physicians if
they resided in Arizona or in other states with only limited Medicaid programs.
In Arizona, poor children saw physicians 40 percent less frequently, and poor rural
residents saw physicians 22 percent less frequently than poor residents of states
with Medicaid programs. Moreover, the proportion of poor Arizona residents who
were refused care for financial reasons was almost double that in states with Medicaid
These findings are consistent with an earlier study which analyzed data from the
1977 National Medical Care Expenditure Survey. In this study, Karen Davis and Diane
Rowland demonstrated that lack of health insurance matters: Financial access to
ambulatory care, in comparison to physical and racial barriers, was the most
important factor affecting use. They showed first, that the insured received 54 percent
more ambulatory care (visits to clinics, doctors' offices or hospital outpatient departments)
than the uninsured; second, that adjusting for health status, the insured in poor health
saw a physician 70 percent more often than the uninsured in poor health; and third, that
the same differentials applied to hospital care-the insured received 90 percent more hospital
care than the uninsured.23 This last point reinforces similar findings by Gail Wilensky
and Marc Berk.24|
A recent study by Kenneth Thorpe and Charles Brecher indicates that the uninsured poor
in cities with public hospitals receive significantly more hospital care than the
uninsured poor in cities without such facilities.25 This conclusion could be used
to argue that public hospitals, and perhaps other health care facilities as well,
may serve to attenuate the disparities in access to medical care. However, it does
not deny the findings by Blendon and his colleagues, nor those by Davis and Rowland,
that public facilities and programs for the poor do not eliminate the systematic
differences in the use of medical care by the insured and uninsured.|
When one compares the care received by the uninsured over time, the evidence appears to
support the argument that the uninsured are receiving less than an adequate level of
care. Such a conclusion is all the more significant when one considers that between
1975 and 1983, following changes in Medicaid eligibility requirements, the proportion
of Americans under the poverty level who were insured by Medicaid fell from 63 to 46
percent, and the number of Americans with no insurance increased by more than 20 percent.26|
In the most recent report on the access of Americans to health care, Harold Freeman and his
coauthors compare the results of their surveys between 1982 and 1986. They note that the gap
between the uninsured and the insured in average number of physician visits increased from
19 to 27 percent during this period. While the gap in receipt of hospital care narrowed,
there is still a 19 percent difference in admission rates between the uninsured and the
insured. Although between 1982 and 1986 the overall use of medical care (physicians and
hospitals) by Americans declined, these surveys indicate that low-income individuals and
minorities in poorer health were affected disproportionately.|
To underscore the above, physician visits for low-income individuals in poorer health
declined by 8 percent, while visits for the nonpoor of similar health status increased
by 42 percent. Also, the average number of physician visits for low-income adults under
age sixty-five declined by 30 percent, but there was no such change for the nonpoor.
Minorities experienced similar relative declines. In 1982 the gap between physician
visits by blacks and whites in fair and poor health was 12 percent, with whites having
a higher number of visits. In 1986, probably as a result of cutbacks in Medicaid
expenditures and eligibility criteria, this gap increased to 33 percent.|
Freeman, et al. also note that 13 percent of the uninsured claimed they did not receive
medical care for economic reasons. The equivalent percentage for the entire population
was six, and for low-income individuals, blacks and Hispanics respectively, 9 percent,
9 percent and 7 percent. Finally, the 1986 survey uncovers significant "underuse" of
medical care. For example, of the total population surveyed, 41 percent who had serious
symptoms did not contact a physician. The equivalent figure for the uninsured
was 67 percent.27 (See Table 2.)|
What must be emphasized about the uninsured is who they are. Predominantly, they
are poor. Thirty-two percent of the poor compared to 10 percent of the nonpoor
have no public or private coverage.28 The percentage of whites with private insurance
was eighty compared to fifty-seven for blacks. This is not surprising since private
insurance is, for the most part, provided by employers, and the unemployment rate is
significantly higher among blacks. Disproportionately more blacks (20 percent) than
whites (12 percent) had neither public nor private health insurance.|
Although, as will be pointed out, there has been great improvement in the United
States in reducing the disparities in use of medical care by socioeconomic status,
the evidence presented above suggests that serious gaps remain. Moreover, the
uninsured have systematically different patterns of health care use in comparison
to the insured. Assuming the insured receive an adequate level of care, the contrast
suggests that the uninsured most likely receive less than an adequate level. Even if
the level of care received in 1982 were defined as adequate, the data from surveys
taken since then which have been summarized here suggest that what the uninsured are
receiving today is less than adequate.|
|The Stronger Equity Criterion
According to the stronger equity criterion, an equitable health care system
should achieve sufficient remedial effects such that health outcomes, as well
as patterns of medical care use, would be independent of an individual's socioeconomic
standing. By this criterion, neither the United States, France, Canada nor Great Britain
comes close to achieving equity. Let us review the evidence, first concerning health
outcomes, and next in relation to the use of medical care.|
|Inequalities in Health Outcomes|
Whether health outcomes are measured in terms of mortality, morbidity or
health status, and whether socioeconomic status is measured by income,
occupation or level of education, much the same picture emerges in all of
these countries: Those at the bottom are worst off. They have the highest
rates of death, disease and functional disability. Consider, for example,
infant mortality rates.|
In the United States, there is no routine data collection procedure linking
infant mortality to the income of the infant's parents. Several studies,
however, provide strong indications. For the period 1964 to 1966, Philip
Hauser and Evelyn Kitagawa showed that infant mortality rates were highly
correlated to family income.29 Another study, comparing poverty and nonpoverty
areas of nineteen large American cities from 1969 to 1971, suggests that infant
mortality rates were 50 percent higher in the poverty areas.30 Often, since there
are no data by socioeconomic status and since it is well known that poverty rates
among blacks are higher than among whites, race is used as a proxy for income.
When this occurs, the differentials appear even more pronounced. Between 1950 and
1980, the ratio of infant mortality rates of blacks to whites increased from
1.6:1 to 1.9:1.31|
In France, demographers have a long tradition of documenting disparities in infant
mortality rates among occupational groups. Although the disparities have
narrowed-at least during the period between 1950 and 1970-the mortality rate
of infants whose fathers are manual workers is still more than twice that of
infants whose fathers are professionals or upper-level managers.32 Moreover,
the ratio of the mortality rate of infants whose mothers are Algerian to that of
infants whose mothers are French was 1.7:1 during the period from 1966 to 1970,
a decrease of only .2 compared to the period 1956 to 1960.33 This disparity is not
limited just to Algerians and to infant mortality. The immigrant or nonimmigrant
status of the mother also is highly correlated with premature births and permatal
Canada, as in the United States, has no routine data collection on infant mortality
rates by income or occupational group. Once again, though, a number of studies provide
reasonably strong indications. For example, in Toronto, Ursula Anderson found that
the lower-income population had infant mortality rates two-and-one-half times higher
than the higher-income population.35 In Montreal, there are no studies
of infant mortality by socioeconomic group, but Russell Wilkins showed that the
average life expectancy was significantly lower in poorer neighborhoods than in
wea1thier ones.36 For the entire province of Quebec, it seems clear that infant
mortality rates are related to the income as well as to the ethnic origin of the
parents. For example, Nouveau Quebec, one of the poorest regions in the province
and one which is populated largely by Inuits (Eskimos), has infant mortality rates that
exceed the average for the province by a factor of three.37|
In Great Britain, data on infant mortality by social class have been collected since
the beginning of this century. As in France, the disparities in infant mortality
rates by social class have narrowed considerably.38 Nevertheless, from 1970 to
1972 the infant mortality rate of those in the lowest class was over twice that
of those in the highest class.39 Moreover, from 1930 to 1972 the overall percentage
decrease in neonatal mortality rates was higher for the two highest classes than for
the two lower ones.40|
Such patterns of differential health outcomes by socioeconomic status can be shown
for a variety of indicators such as standardized mortality rates, age-specific
mortality rates and life expectancy. What is more, there is a range of health
status indicators which are also highly correlated socioeconomically. For example,
measures of various activity limitations such as "restricted activity days" or
"bed disability days" indicate that the poor tend to suffer disproportionately-at
least in the United States, Canada and Great Britain where such data, based on
surveys, are readily available.41|
|Inequalities in the Use of Medical Care|
As in the case of health outcomes, whether the use of medical care is measured
by physician visits, hospital admissions or length of stay, and no matter how
socioeconomic status is measured, there are common patterns of inequality in
the United States, France, Canada and Great Britain. The use of physician
services is an example.|
Following the establishment of Medicare and Medicaid in the United States,
NHI in France and Canada and the NHS in Britain, there was evidence of redistribution
of ambulatory care services. Those in the lower-income brackets increased significantly
their use of physician services; those in the upper-income brackets slightly decreased
theirs.42 In interpreting these changes, however, given that the poor tend to be sicker
than upper-income groups, it is crucial to adjust the data on physician visits for
differential health status.43 In all four countries, although the poor tend to visit
physicians more frequently than those with more income, once these adjustments are made,
there is still evidence of significant inequalities.|
In the United States, based on the 1969 Health Interview Survey, Karen Davis
adjusted data on physician visits for differences in need and found that all
persons with family incomes under $15,000 made 3.7 annual adjusted visits to
physicians, while those with family incomes over $15,000 made 5.2.44 In a later
study based on the 1976 to 1978 Health Interview Survey, Joel Kleinman, Marsna
Gold and Diane Makuc adjusted data on physician visits for differences in health
status and found similar inequalities. Depending on the measure used to assess
health status, they found that the poor have between 7 percent and 44 percent
fewer physician visits than those with income above twice the poverty level.
Moreover, they found that the poor are far more likely to use hospital clinics
and less likely to use private physicians' offices.45|
In France, similar findings based on survey data reveal the extent of inequalities
under NHI. Although there are no data available on physician visits by socioeconomic
status that are adjusted for levels of health status, Georges Roach and his colleagues
used an indicator of morbidity to so adjust data from a survey of medical care
consumption patterns in the Paris region.46 They found that, holding morbidity
constant, upper-level managers had a consumption index equal to over twice that
of manual workers. Subsequent studies have not updated this work, but the 1970
and 1980 French national surveys of medical care use reveal strikingly different
patterns by socioeconomic standing.|
For example, both in 1970 and in 1980, manual workers made significantly more
visits to general practitioners than upper-level managers. Conversely, upper-level
managers made far more visits than manual workers to specialists, radiologists,
dentists and physical therapists.47 Such differentials in patterns of medical
care use are also found between ethnic groups in France, even for such basic
services as prenatal care. Only 9 percent of French women do not complete their
required four prenatal visits, but this figure reaches 20 percent for all immigrant
women and 25 percent for all North African women living in France.48|
In Canada, also, there are indications that NHI does not meet the stronger equity
criterion regarding the use of physician services. In a study of the universal and
comprehensive medical insurance plan in the province of Saskatchewan, Robin Badgely
and others concluded that although use of medical services by all groups had
increased, there was little change in the relationships between one's
socioeconomic position and the use of medical services.49 Subsequently,
for the period 1963 to 1968, Beck found considerable inequalities in access
to physicians' services by income class, particularly for specialist services,
complete examinations and laboratory testing.50 Although the disparities were
reduced over the time of the study, they were not removed.|
In a study of the use of physician services in the metropolitan area of Montreal,
Philip Enterline and his colleagues noted the changc from a positive correlation
of use with socioeconomic status a year before Medicare, to a negative correlation
a year after its introduction.51 Similarly, in a national study of medical and
hospital use, Statistics Canada noted that lower-income people had a higher
incidence of medical care use than those in higher-income groups.52 Neither
of these studies, however, adjusted for health status between these groups.|
The one Canadian study that has made the adjustment for health status provides
mixed results.53 For those patients who had reported being sick in the past four
weeks, a higher percentage of patients in the low economic class reported seeing
a doctor than in the high economic class. Conversely, for those patients who
reported not being sick in the past four weeks, a higher percentage of patients
in the high economic class reported seeing a doctor than in the low economic class.
Moreover, a significantly higher proportion of patients in the high economic class
(85 percent) reported seeing their doctor in a private office than those in the low
economic class (60 percent). Nearly all those who did not see their doctor in a
private office went to hospital clinics or emergency rooms.54|
In Great Britain, as in the United States, France and Canada, data from the
General Household Survey, reported in The Black Report, generally confirm
that use of general practitioner services is higher for groups with a lower
socioeconomic status than for those with a higher one.55 After adjusting
these data for differential health status, though, with the exception of
one important study by Elizabeth Collins and Rudolf Klein, most of the
evidence suggests that the higher classes make more use of general
practitioner services than the lower classes.56 But even this evidence
probably underestimates the disparities because, as Richard Titmuss argued,
the well-to-do know how to make better use of the system.57 They know how to
get through the "gatekeeper" to confer with hospital-based consultants, i.e.,
In addition to knowing how to use the system, The Black Report emphasizes
that the higher socioeconomic groups make more use of preventive and health
promotion services.58 For example, Ann Cart-wright notes that there are clear
class gradients in the proportion of mothers receiving prenatal care.59 Similar
gradients apply for the provision of dental services.60 The Black Report also notes
that hospital outpatient departments and emergency departments are used more by
the working class than by the middle class. Furthermore, the lower socioeconomic
groups receive less consulting time than do the upper ones.61|
Such patterns of differential socioeconomic use of physician services can also be
shown for hospital admission rates and lengths of stay. As a general rule, the poor
tend to have higher admission rates and lengths of stay-not only in the United States
but in France, Canada and Britain, as well.62 This relatively high use of hospital
services no doubt reflects the poorer heath status of lower-income groups and their
different patterns of using ambulatory care services.|
|Methodological Problems in Comparing Inequalities|
In applying the stronger equity criterion to the evaluation of health care
systems, it is tempting to draw conclusions about the extent of health
inequalities in the United States as compared to France, Canada and Great
Britain. Such a cross-national approach would attempt to compare the extent
of inequalities across each system at approximately one point in time. An
alternative, longitudinal approach would compare rates of change within each
system toward or away from equality. Both approaches, along with the methodological
problems they engender, are called out in Table 3 pertaining to infant mortality,
and in Table 4 with respect to physician visits.|
The problem in working with data derived from national surveys is the risk related
to sampling errors and the validity of the instrument itself. The problem in
relying on local studies, on the other hand, is whether any valid inferences
can be drawn for the whole country. The more overwhelming problem, however,
in assessing the extent of health inequalities across countries is the
unavailability of comparable data. Each country and each study has its own
way of measuring socioeconomic status, and since studies of health inequalities
are not done with great frequency, it is difficult to find comparable studies
that focus on the same point in time.|
The problem of comparing different measures of socioeconomic status is
particularly vexing. It is difficult enough to develop measures which
reflect levels of income, wealth, occupational status, education and a
host of other factors. What makes cross-national comparisons so problematic
is that each country has either developed or explicitly not developed its own
unique national taxonomy. For example, in Great Britain the General Household
Survey uses five occupational groupings: Class I consists of high-level professional
and administrative occupations-5 percent of the population; Class II consists of
employers in industry and retail trades and the lower-level professions-18
percent of the population; Class III is comprised of skilled workers-50 percent of
the population; Class IV is made up of partially skilled workers-18 percent of the
population; and Class V encompasses unskilled workers-9 percent of the population.
In France, the Institut National de Statistiques et Etudes Economiques (INSEE)
classifies socioeconomic status according to ten categories: high-level professionals
and executives; middle-level managers; business and commercial proprietors; skilled
workers; specialized workers; manual workers; employees; agricultural workers;
salaried agricultural workers; and miners. What is important to observe here is
that some nation's studies rely on occupational groupings; others on educational
attainment; and still others on income categories such as "poor" and "nonpoor."|
Given these differences in socioeconomic groupings, even after measuring health
inequalities, for example, by calculating the ratio of the lowest to the highest
group, it would be misleading to draw any conclusions on the relative degrees of
inequality at any given point. It would also be misleading to draw any inferences
about the relative rates of progress toward equality, which are shown in
Tables 3 and 4. The reason is that the relative size of each socioeconomic grouping
has changed at different rates within each country, and calculating these rates gets
very problematic due to different rates of inflation and different methods of
calculating real income.
With regard to the stronger equity criterion, one of the more promising
areas for comparison would be to examine the extent of inequality among
socioeconomic groups in physician visits adjusted for health status, Yet,
once again, there are not only the methodological problems related to cross-national
and longitudinal analysis, but also the problem of developing valid indicators
of need. Each country has relied on different data and methods for adjusting
their figures on physician visits. This means that the British "use/need"
ratios are really not comparable to the various American calculations of
adjusted physician visits and to the limited number of French and Canadian
studies.63 This explains why Table 4 displays only physician visits with no
adjustments for health status.|
On the basis of the weak equity criterion, the United States is the least
equitable health care system in comparison to France, Canada and Great Britain,
because it is the only country where a significant portion of the population is
uninsured. This status, which unquestionably affects the patient's ability to pay,
means that providers are at risk for what has come to be known as "bad debt"
or "uncompensated care."|
From a private, office-based physician's perspective, there is no obligation
to serve such patients. From a private hospital's perspective, as a general rule
it is best to minimize such risk and ration costly resources either by transferring
patients or by providing fewer services to them.|
In France, Canada and Great Britain, since almost all hospitals are reimbursed
on the basis of global budgets, there is also an incentive to ration costly
resources, and problems of patient dumping do occur. This affects the elderly,
the mentally ill, alcoholics and other, less desired patients. British
consultants, for example, refer to "bed blocking" when such patients take up badly
needed space. The United States, however, is the only country in this comparison
where there exist systematic inequalities, based on ability to pay, in the health
services received by the uninsured as compared to the insured. Although the
uninsured usually receive some basic minimum care, as noted earlier, the evidence
suggests that what they receive is less than adequate.|
Regarding the stronger equity criterion, the extent of inequalities- both in
relation to health outcomes as well as to the use of medical care-is clearly
significant and pervasive. It appears to make little difference whether a health
system is public or private or, for that matter, anywhere between the two ends of
this continuum. In an insightful book which compares the health systems in the
United States and Britain, J. Rogers Hollingsworth compares a number of measures
of inequality and asserts that "if class inequalities in access to care still
exist in England and Wales, they are substantially less than in the United States
or at earlier times." 64|
However, the methodological problems of comparing inequalities in health make
it extremely difficult to compare the degree of inequality between different
health care systems. Indeed, in his concluding observations, Hollingsworth
admits that "[t]he data here do not permit any definitive conclusions about
the relationships between changes in the organization and technology of medical
care services and changes in health across social classes and regions."65|
What, then, may one conclude from this analysis of inequalities in public
versus private health systems? Certainly, evaluating health systems on the
basis of the stronger equity criterion appears to resemble what Odin Anderson
called "an endless search for the dream." In this sense, this criterion is an
elusive goal, which makes it a "weak test" of a health system's capacity to
achieve equitable access to medical care services. In contrast, the weak concept
of equity is a "strong test"-at least with regard to the health care system in
the United States-because it has been achieved in France, Canada and Great Britain.|
- Odin W. Anderson, Health Care: Can There Be Equity? (New York: Wiley
& Sons, 1972), Part IV, p. 161.
- For a review of this literature, see Diana B. Dutton, "Social Class, Health and Illness," in Linda Aiken and David Mechanic, eds., Applications of Social Science to Clinical Medicine and Health Policy (New Brunswick, NJ: Rutgers University Press, 1986), pp. 31-62.
- See, for example, Norman Daniels, "Equity of Access to Health Care:
Some Conceptual and Ethical Issues," Milbank Memorial Fund Quarterly 60: 1 (Winter 1982): 51-81.
- See, for example, LuAnn Aday and Ronald Andersen, "Equity of Access to Medical Care: A Conceptual and Empirical Overview," Medical Care 19: 12 (Supplement 1981): 4-27.
- The only other attempts to study these issues in a cross-national perspective of which I am aware are: Pranlal Manga and Geoffrey R. Weller, "The Failure of the Equity Objective in Health: A Comparative Analysis of Canada, Britain and the United States," Comparative Social Research 3 (1980): 229-267; and Sir Douglas Black, et al., and Peter Townsend and Nick Davidson, eds., Inequalities in Health: The Black Report (New York: Penguin, 1982), chapter 5 (hereinafter, The Black Report). I have benefited greatly from both studies.
- A comprehensive survey of recent thinking on this issue may be found in the three volumes of the President's Commission for the Study of Ethical Problems in Medicine: Biomedical and Behavioral Research, Securing Access to Health Care: A Report on the Ethical Implications of Difference8 in the Availabilily of Health Care Services (Washington, D.C.: U.S. Government Printing Office, 1983).
- George Orwell, Animal Farm (New York: Harcourt, Brace & Co., 1946).
- For a helpful conceptual framework in analyzing equity in school financing, see Robert Berne and Leanna Stiefel, The Measurement of Equity in School Finance (Baltimore: The Johns Hopkins University Press, 1984).
- Daniels, op. cit. note 3; and Alain Enthoven, Health Plan: The Only Practical Choice to the Soaring Cost of Medical Care (Reading, MA: Addison-Wesley, 1980). See Enthoven's description of the Consumer Choice Health Plan at pp.
- President's Commission, op. cit. note 6, Vol. 1, p. 4.
- LuAnn Aday, Ronald Andersen and Gretchen V. Fleming, Health Care in the U.S.: Equitable
for Whom? (Beverly Hills, CA: Sage Publications, 1980), p.4.
- See, for example, Vicente Navarro, "The Public/Private Mix in the Funding and Delivery of Health Services: An International Survey," American Journal of Public Health 75: 11 (November 1985): 1318-1320; or Gordon McLachlan and Alan Maynard, eds., The Public/Private Mix for Health (London:
The Nuffield Provincial Hospitals Trust, 1982).
- Victor Rodwin, "American Exceptionalism in the Health Sector: The Advantages of Backwardness' in L~arning from Abroad," Medical (~tLrr Review 11: 1 (Spring 1987): 41.
- Alan Maynard and Alan Williams, "Privatization and the National We!fare State," in Julian LeGrand and Ray Robinson, eds., Prititisation and the WeU.r~ Si~iie (London: George Allen and Unwin, 1~i~i), pp. 95-110.
- Estimates of the number of the uninsured range from 15 to 20 percent of the population. In 1984, the Current Population Survey of the U.S. Bureau of the Census estimated that 35.1 million people, 17.1 percent of the population ur~u.r age sixty-five, wi~re withou: insurance. The percentage increases if one broadens the definition to include the underinsured and those otherwise medically disadvantaged. ~e Margaret B. Sulvetta and Katherine Swartz, The Uninsured and Uncompensated Core: A Charlbook (Washington, D.C.: National Health Policy Forum, George Washington University, 1986).
- For an overview of the French Nil! system, see Victor Rodwin, "The Marriage of National Health Insurance and La Medécine Libérale: A Costly Union," A! hn-~k Memorial b'nni Quar~rLb 59: 1 (Winter 1981): 16-43.
- For an overview of Canadian national health insurance, see Spyros Andreopoulos, ed., National Health Insurance: Can We Learn From Canada? Sun Valley Forum on Nat~:~al health (New York: John Wiley & Sons, 1975).
- A National Health Service (London: UMSO, L)14, Cmnd. 6502).
- President's Commission, op. cit. note 6, Vol. 1, p. 1.
- Henry J. Aaron and William B. Schwartz, The Painful Prescription: Rationing Heali~ Care (Washington, D.C.: Brookings In.'~titute, 1984).
- Dumping patients has become a major public issue; at the time of this writing, a congressional committee is investigating allegations th~t some hospitals ~ in this practice.
- Robert J. Blendon, Linda Aiken, Howard Freeman, Bradford L. Kirkman-Luff and John W. Murphy, "Uncompensated Care by Hospitals or Public Insurance for the Poor: Does It Make A Difference?" New England Journal of Medicine 314: 18 (M~ty 1, 1986): 1160-1163.
- Karen Davis and Diane Rowland, "Uninsured and Underserved: Inequities in Health Care in the United States," Milbank Memorial Fund Quarterly 61: 2 (Spring 1983): 149-176.
- Gail R. Wilensky and Marc L. Berk, "The Health Care of the Poor and the Role of Medicaid," Health Affairs 1: 4 (Fall 1982): 93-100.
- Kenneth Thorpe and Charles Brecher, "Irnpruved Access to Care for the Uninsured Poor in Large Cities: Do Public Hospitals Make A Difference?"
Journal of health Politics, Policy and the Law 12: 2 (Summer 1987): 313-324.
- Blendon, et al., op. cit. note 22.
- Howard E. Freeman, Robert J. Blendon, Linda Aiken, Seymour Sudman, Connie Mullinix and Christopher R. Corey, "Americans Report on Their Access to Health Care," Health Affairs 6: 1 (Sprin~ 1987): 6-18.
- Ronald Andersen, Meei-Shia Chen, LuAnn Aday and Llewellyn Cornelius, "Health Status and Medical Care Utilitization," health Affairs 6: 1 (Spring 1987): 136-156.
- Evelyn M. Kitagawa and Philip M. Hauser, Differential Mortality in the United States: A Stu4y in Socioeconomic Epidemiology (Cambridge, MA:
Harvard University Press, 1973).
- U.S. Department of Health, Education and Welfare, health of the Disadvantaged: Chartbook (Washington, D.C.: U.S. Government Printing Office, Pub. No. (HRA) 77-628, 1977).
- U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, Health: United Stales 1985 (Washington, D.C.: U.S. Government Printing Office, Pub. No. (PHS) 85-1232, 1985), p. 54.
- Marcel Crozé, "Mort.alité infantile des générations 1950-1951 et 1955 a
1960 suivant le milieu social et la residence," ctudes el Documents Demographiques, No. 9 (Paris: INSEE, 1965); and Solange Héméry and Marie-Claude Gerard, "Mort.alité infantile en France selon !e milieu social," in International Union for the Scientific Study of Population, Proceedings, International Populotion Conference 1973(Liege: IUSSP, 1973), Vol. 3, pp. 171-184.
- Data are based on a survey of eleven thousand births published by INSERM in 1980. See ~Systéme de Soins et Solidarité: Les Inegalités Sociales et Geographiques et Quelques Contradictions dans le Fonctionnement Actuel du Systeme (Paris: Documentation Française, 1981), p. 23.
- Ursula M. Anderson, "Infant Survival Differentials in the City of Toronto: A Challenge to Health Planning and Research," Canadian Family Physician 16 (1970): 45-50.
- Russell Wilkins, L'Espérance de Vie Par Quartier A Montreal, 1976: Un Indicateur Social pour Ia Planification (Montreal: Institute for Research on Public Policy, April 1979).
- Robert Pampalon, Geographie de Ia Sante au Quebec (Quebec: Government of Quebec, Ministry of health and Social Services, 1985), pp. 287, 361 and 369.
- See Avedis Donabedian, Soloman J. Axelrod and Leon Wyszewianski, eds., Medical Care Chartbook, '7th ed. (Washington, D.C.: AUPHA Press, 1980),
- The Black Report, op. cit. note 5, p. 52.
- Ibid., Table 10, p. 71.
- Data on the United States are routinely collected in the National Health
Interview Surveys. For a thorough analysis of these data, see Paul Newachek,
Lewis Batler, Aileen K. Harper, Dyan Piontkowski and Patricia Franks, "Income
and Illness," Medical Care 18: 12 (December 1980): 1165-1176. Data for Great
Britain are routinely collected in the General Household Survey. See The Black
Report, op. cit. note 5, Table 12, p. 73. For an analysis of similar data from
Canada, see Russell Wilkins and 0. Adams, Healthfulness of Life: A Urnfled View
of Mortality, Institutionalization, and Noninstitutionalized Disability
in Canada (Montreal: Institute for Research on Public Policy, 1978).
- Donabedian, et al., op. cit. note 38, for data on the United States (p.
35), England and Wales (p. 51) and Quebec (p. 53).
- There is a wide range of methods for adjusting data on physician visits for differential health status. Each country has relied on its own. For example, in Great Britain, data from the General Household Survey on rates per thousand people of general practitioner consultations in a two-week period are divided by the prevalence rate per thousand people of chronic handicapping illness. In the United States, the National Center for Health Statistics collects data for a use-disability index that summarizes the ratio of mean physician visits to mean disability days for respective age and income groups.
- Karen Davis, "Medicaid Payments and Utilization of Medical Services by the Poor," Inquiry 13: 2 (June 1976): 122-135.
- Joel C. Kleinman, Marsha Gold and Diane Makuc, "Use of Ambulatory Care by the Poor: Another Look at Equity," Medical Care 19: 10 (October 1981): 1011-1029.
- The survey was conducted in 1965 and 1966. See J. Devouassoux, B. Morel and D. Polton, "Recours Aux Soins et Inegalités de Sante," Sante Securité Sociale-Statisliques et Commenlaires 3 (Mai-Juin 1982): 27-48; see especially Tableau 11, p. 39. Also see Michel Magde!aine, Andree and Arié Mizrahi, and George Roach, "Un indicateur de Ia Morbidite appliqué aux données d'une enquête sur la consommation médicale," Consommation 14: 2 (Avirl-Juin 1967):
3-41 (Centre des Recherches et de Documentation sur la Consommation).
- Devouassoux, et al., op. cit. note 46, Tableau 9, p. 37.
- Marc Gentilini, Gilles Brücker and Robert de Montvalon, Le sante des migrants: rapport au ministre de Affaires sociales et de La Solidarité nationals, et au secretaire d'Etat chargé de La Sante (Paris: La documentation française, 1986), p. 42.
- Robin B. Badgley, Robert W. Hetherington, V. L. Matthews and Marjorie Schulte, "The Impact of Medicare in Wheatville, Saskatchewan, 1960-1965," Canadian Journal of Public Health 58: 3 (March 1967): 101-108.
- R. G. Beck, "Economic Class and Access to Physicians' Services and Public Medical Care Insurance," International Journal of Health Services, Planning, Administration, Evaluation 3: 3 (Spring 1973): 341-355.
- Philip E. Enterline, Vera Salter, Alison D. McDonald and J. Corbett McDonald, "The Distribution of Medical Services Before and After 'Free' Medical Care-The Quebec Experience," New England Journal of Medicine 289:22 (November 29, 1973): 1174-1178.
- Statistics Canada, Distributional Effects of Health and Ed ucational Benefits in Canada, 1974 (Ottawa: Queen's Printer, 1977).
- Jack Siemiatycki, Lesley Richardson and Ivan Barry Pless, "Equality in Medical Care under National Health Insurance in Montreal," New England Journal of Medicine 303: 1 (July 3, 1980): 10-14.
- Even after Medicare, the emergency room remains the usual source of care for a disproportionate share of the lower social classes in Montreal. See Nicholas Steinmetz and John R. Hoey, "Hospital Emergency Room Utilization in Montreal Before and After Medicare," Medical Care 16: 2 (February 1978): 133-199.
- The Black Report, op. cit. note 5, p. 96.
- Elizabeth Collinsand Rudolf Klein, "Equity and the NHS: Self-Reported Morbidity, Access and Primary Care," British Journal of Medictne 281 (October 25, 1980): 1111-1115. The other studies include J. Brotherston, "Inequality: Is It Inevitable?," in C. 0. Carter and John Peel, eds., Equalities and Insqualities in Health: Proceedings of the 12th Annual Symposium of the Eugenics Society (London and New York: Academic Press, 1976); and B. P. Forster, "Social Class Differences in Sickness and General Practitioner Consultations," Health Trends 8:2 (May 1976): 29-32. See also The Black Report, op. cit. note 5, Table 13, "Use/Need Ratios by Social Group," p. 77.
- Richard Morris Titmuss, Commitment to WeLfare, 2nd ed. (London: Allen & Unwin, 1968).
- The Black Report, op. cit. note 5, pp. 81-84; and Margaret Bone, Family Planning Services in England and WaLes.~ An Inquiry Carried Ow on BehaLf of the Department of Health and Social Security (London: HMSO, 1973).
- Ann Cartwright, Parents and Family Planning Services (London: Rout-ledge & Kegan Paul, 1970).
- See John S. Bulman, et al., Demand and Need for Denial Care (Oxford, England: Oxford University Press, 1968); and P. G. Gray and the Department of Health and Social Security, Adult Denial Health in England and Wales in 1968 (London: HMSO, 1970).
- Ann Cartwright, Human Relations and Hospital Care (London: Routledge and Kegan Paul, 1964); Ann Cartwright and Maureen O'Brien, "Social Class Variations in Health Care and in the Nature of General Practitioner Consultations," in Margaret Stacey, ed., The Sociology of the National Health Service, Sociological Review Monograph No.22 (Keete, England: University of Keele Press, 1976), pp. 77-98.
- For data on the United States, see Joel Kleinman, "Medical Care Use in
Nonmetropolitan Areas," in U.S. Department of Health and Human Services,
Public Health Service, National Center for Health Statistics, Health: United
Slates 1981 (Washington, D.C.: U.S. Government Printing Office, Pub. No.
(PHS) 82-1232, 1981), pp. 55-61.
- See endnote 43.
- J. Rogers Hollingsworth, A Political Economy of Medicine: Great Britain and the United States (Baltimore: The Johns Hopkins University Press, 1986), p. 191.