As George Orwell, a self-proclaimed democratic socialist once wrote: “All animals are equal, but some animals are more equal than others.”1 Not even Orwell himself could have envisioned that his satirical revelations on communism would today reflect the underpinnings of cynicism aimed directly at the very foundations of Canada's socialized health care system.
The Canadian health care system is predicated on several basic principles. These include universal coverage without out-of-pocket payment or user fees for all medically insured services, portability of benefits across provinces, and the transfer of payments and control from the federal government down to local provincial authorities.2 Among the main impetus for Canadian social health reform in the 1960s was the view that health care was a “basic right” of Canadians and that no citizen, no matter how economically disadvantaged, should ever be denied access to necessary medical health care services. Implicit in the initial expectation was the belief that a national universal health insurance program would help to sever the link between poverty and illness by delivering care on “uniform terms and conditions,” thus eliminating economic access barriers to health care in this country.3 Universal health care is heralded as the most popular of all Canadian public programs; it is also the envy of many nations worldwide.
In this issue of the Journal, Pilote4 directly challenges Canada's egalitarian health care principles by examining whether socioeconomic status affects access to invasive cardiac procedures after acute myocardial infarction (AMI) in Quebec, Canada. Using ecological measures of socioeconomic status (eg, neighborhood income, average rent, proportion of renters within a neighborhood), the authors demonstrate that patients residing in lower socioeconomic areas are less likely to receive coronary angiography at 7 days, 30 days, and 90 days after AMI as compared with their more affluent counterparts, with absolute differences ranging from 10% to 30%, depending on a host of factors (eg, AMI year, time interval after AMI, sex). In contrast, the authors found no significant relation between socioeconomic status and the utilization of myocardial revascularization among patients who had already received coronary angiography after AMI. The authors conclude that universal health insurance coverage does not eliminate socioeconomic access inequities to cardiac catheterization after AMI.
Taken in isolation, the results by Pilote provide little in the way of any new or compelling information regarding socioeconomic access barriers in Canada for two important reasons. First, socioeconomic data were obtained through the use of ecologic rather than individual-level data. Second, no clinical information regarding infarct severity or other coexisting conditions was available. In the end, the authors do not and cannot conclude that the socioeconomic angiography differences observed in their study are necessarily inappropriate. Nonetheless, when interpreted within the context of other studies, the findings by Pilote assume greater relevance and reinforce the consistency by which socioeconomic factors influence physician referral behaviors throughout many regions across Canada. Highlighted below are just a few examples in Ontario, Canada's largest province.
Among 51,591 patients hospitalized with AMI in Ontario between April 1994 and March 1997, our group previously demonstrated that each $10,000 increase in neighborhood income was associated with an increase of 18% in the rate of coronary angiography within 6 months after AMI, after adjusting for age, sex, and coexisting conditions.5 In another survey examining the perspectives of Ontario health care providers, the vast majority of respondents acknowledged having been involved in the treatment of patients who had received preferential access to specialized cardiac services on the basis of factors other than medical need; these included personal connections or ties to the treating physicians, social community standing, and affluence.6 In an unrelated 1990 Ontario survey, McIsaac et al7 demonstrated that even after controlling for self-reported health care needs, persons with higher socioeconomic status were more likely to visit specialists, whereas those of lower socioeconomic status receive greater use of general practitioners' services. Whereas the underlying reasons for socioeconomic treatment disparities remain unclear, these studies, when taken together, challenge the egalitarian principles of Canada's health care system, especially when considering that those patients who are most socially disadvantaged are also often the individuals with poorest health status and outcomes.8
One reasonable question then follows: To what extent, if any, has the introduction of universal health care succeeded in improving access impediments to medical services for socioeconomically disadvantaged Canadians?
In the years preceding universal health care, it was estimated that nearly one half of Canadians had either limited or no medical coverage; included among them were low or modest income earners and those citizens residing in rural communities.3 Using these numbers as historic controls, available evidence would suggest that considerable gains have indeed been achieved in mitigating the impact of socioeconomic status on access to medical services in Canada. Notwithstanding the relative differences in the use of coronary angiography across socioeconomic subgroups, Pilote did demonstrate that 33% of men residing in low-income neighborhoods (as compared with 47% of men from high-income neighborhoods) still received coronary angiography after AMI. Moreover, the authors noted no socioeconomic disparities in that referral rates for revascularization among those patients who had undergone angiography.4 These findings, coupled with evidence from other Canadian studies demonstrating similarities in the provision of primary care services between wealthy and impoverished citizens, suggest important positive strides in social reform with the advent of a publicly funded national insurance system in Canada.7, 9
Although many may acknowledge the theoretical merit behind universal health care, there are those who view the successes of Canada's Medicare program less enthusiastically. Critics point out the steady growth in health expenditures required to sustain universal health care in Canada. For example, between the years of 1960 and 2000, health expenditures rose from 5.4% to 9.1% of Canada's Gross Domestic Product (fifth among all OECD nations).10 Rising health care costs have been accompanied by increases in overall service demands, which have arisen from a host of factors (eg, improved AMI survival rates, broadening indications for diagnostic and therapeutic interventions, etc.). Fiscal pressures have necessitated cost containment initiatives and in some cases, overt system rationing. The ensuing mismatch between supply and demand has resulted in lengthy queues, where patients may be triaged according to factors other than clinical urgency or need.6, 11 Disconcertingly, recent evidence suggests that socioeconomic angiography disparities after AMI in Ontario may actually be diverging over time, despite an accelerated growth in cardiac catheterization service capacity.12
Opponents of Canada's national health insurance system may also argue that universal health care has not necessarily affects socioeconomic differences in health outcomes. For example, among 51,591 patients with AMI who were hospitalized in Ontario in the cohort described above, 1-year survival rates for those residing in poorer neighborhoods were 6% lower than those residing in the most affluent neighborhoods.5 After adjusting for baseline factors, each $10,000 increase resulted in a 10% decrease in mortality rates at 1 year after AMI. Finally, although Canadians have had an overall improvement in health status over the past several decades (as exemplified by lower infant mortality rates and higher average life expectancies), critics cite that a large proportion of such improvements predated the inception of universal health insurance by several years.3
In summary, Canada's public payer system has brought about sizable increases in health expenditures, which have not always been sustainable. Moreover, increases in supply have been offset by the inflation in demand; the net result of which has been the emergence of lengthy queues. Queues, when managed implicitly, may be subjected to biases that will tend to favor the socially affluent or those who are best connected with either managing physicians or with the system itself.6, 11 Although the elimination of user fees has helped mitigate the impact of socioeconomic status on access to medical services, it has not removed socioeconomic access impediments entirely. Indeed, socioeconomic -treatment gaps remain and may well be increasing with time.12 Since the inception of universal health care, Canadians have witnessed a steady improvement in overall health status and life expectancy; yet, the extent to which such improvements can be attributed to universal health insurance is debatable. Finally, the irreconcilable link between poverty and illness has not been severed.
Pilote stopped short in offering solutions that address socioeconomic disparities in the provision of specialty care. However, there are no shortages of opinion. There will be some who will draw upon studies like those of Pilote as evidence that the overarching principles of equity are unrealistic goals and may push instead for a reestablishment of private payer systems and/or user fees. There will be others who will argue that policy makers have focused too heavily on health care delivery at the expense of other social reform programs aimed at eliminating poverty in society. At the core of such arguments is the fundamental belief that it is factors beyond the provision of health care services that ultimately account for wealth-health gradients in society.
In November 2002, the commission on the future of health care in Canada tabled its final report, recommending significant increases in federal expenditures for health care over the next several years.13 Although priority programs were identified (eg, funding for a rural and remote access fund), the link between poverty and illness was not specifically addressed. In this regard, the report opted for a “status quo” approach to Canada's health care future. Although increased federal expenditures will undoubtedly result in much-needed improvements in the provision of selected services, one outcome is certain. Based on the current and historic trends, socioeconomic gaps in health care delivery and outcomes will continue to exist in the future and may do so in greater magnitudes than at present. In this regard, Orwell's words should serve as a prophecy to Canadians about the future expectations of our health care system: “Not all Canadians will be equal, and some Canadians will be less equal than others.”
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