Robin Osborn, Cathy Schoen, Phuong Trang Huynh, Alyssa L. Holmgren
P. T. Huynh, C. Schoen, R. Osborn, and A. L. Holmgren, The U.S. Health Care Divide: Disparities in Primary Care Experiences by Income, The Commonwealth Fund, April 2006
Given the strong correlation worldwide between low income and poor health—including disability, chronic disease, and acute illness—it is especially critical for people with limited incomes to have ready access to medical care. Inequities in access can contribute to and exacerbate existing disparities in health and quality of life, creating barriers to a strong and productive life.
Low-income patients in any country are likely to be particularly vulnerable to policies related to health insurance. Gaps in coverage, patient cost-sharing, and limited benefits can all act as barriers to care. To the extent that higher income enables patients to avoid waiting lists, complex administrative processes, or community shortages, nonfinancial barriers may also contribute to inequities in care experiences.
Cross-national comparisons of health care experiences by income can help in the assessment of relative performance and can provide guidance to policymakers seeking to reduce health and health care disparities. To compare experiences in countries with different health insurance and care delivery systems, The Commonwealth Fund 2004 International Health Policy Survey interviewed adults in Australia, Canada, New Zealand, the United Kingdom, and the United States about their primary care experiences. A 2004 report based on the survey found shortfalls in the delivery of timely, effective, safe, or patient-centered care, with significant differences across all five countries. Although country rankings varied, on average the U.S. often ranked low, particularly with regard to stability of physician–patient relationships, concerns with coordination of care, and cost-related barriers.
This report goes beyond the averages to compare experiences within and across the five countries by income. The study examines how adults with below-average incomes fare within each country's health system and how their experiences compare with those of adults with above-average incomes.
Overall, the report finds a health care divide separating the U.S. from the other four countries. The U.S. stands out for income-based disparities in patient experiences—particularly for more negative primary care experiences for adults with below-average incomes. On most measures of primary care access, coordination, and doctor–patient relationships, below-average-income adults in the U.S. had the worst experiences compared with their counterparts in the other four countries. Only on selective preventive care measures did below-average-income adults in the U.S. fare better than in the other countries.
In the U.S., disparities—many of them wide—between below-average- and above-average-income adults' experiences were evident on 21 of 30 measures. At the other end of the spectrum, the U.K. was the most equitable in terms of reported care experiences. Compared with the U.S., there were also relatively few disparities by income in Australia, Canada, and New Zealand; in these countries, significant differences arose most often for access to services not fully covered by public insurance.
Among the five countries, the U.S. was unique in the extent to which differences by income extended to patient–physician care relationships and ratings. In the other four countries, lower-income and higher-income adults tended to report similar physician experiences.
The study also finds that uninsured adults in U.S. are at sharply elevated risk for access barriers, coordination gaps, and other primary care deficiencies. Yet, being uninsured is only part of the story: even when insured, below-average-income American adults under age 65 were more likely to report access problems and delays than insured, above-average-income adults.
Following are some key highlights from the study.
Low-Income Adults Across Five Countries
Compared with below-average-income adults in the other countries, those in the
The U.S. performs comparatively well on clinical preventive care measures, regardless of income level. In these indicators, U.S. below-average-income adults tended to lead rather than lag their counterparts in other countries.
Disparties by Income
Despite health care spending that far outstrips that of the other four countries, the U.S. lags behind in provision of timely, patient-centered, and efficient care for its below-average-income population. The U.S. also stands out for systemic differences in access to care and primary care experience by income.
In the U.S., health insurance coverage is associated with access to care and better care experiences. Uninsured adults were the most likely of adults in all five countries to go without care because of costs and to experience coordination problems that put their health at risk and undermine the efficiency of care. The cross-country findings further indicate that below-average income adults are likely to be particularly sensitive to insurance design, including cost-sharing and benefits. In Australia and New Zealand, disparities by income level emerged for services less well covered by national plans, despite fees that would be considered modest by U.S. standards. Within the U.S., the persistence of access problems among below-average-income adults with insurance coverage likely reflects the shift in insurance design toward higher deductibles and cost-sharing.
Finding policy solutions to extend coverage and improve primary care for lower-income adults is a critical step toward improving the performance of the U.S. health care system. The experiences of other countries indicate that it is possible to do better.