Health insurance markets and income inequality: findings from an international health policy survey

Objective: To assess disparities in access to health care, financial burden of medical bills and perceived quality of care between those with above av erage incomes and those with below average incomes in five nations and to e xamine the relationship of inequities in care experiences to health insuran ce coverage. Design: Cross-sectional analysis of a random survey of adults in 1998. Subjects: 5059 adults ages 18 and over in five English-speaking co untries: Australia, Britain; Canada, New Zealand and the United States (app roximate to 1000 per country) Main outcome measures: Failure to receive nee ded carl, difficulty getting care, waiting time for elective surgery, probl ems paying medical bills, failure to fill prescriptions due to cost, percei ved qualify of medical care received and of most recent doctor visit. Resul ts: There were two to three-fold differences between those with above and b elow average incomes on measures of access to care in the US, Australia and New Zealand. In Britain and Canada indicators of access to cars were simil ar for the two income groups. Problems paying medical bills were most preva lent in the US. yet significant differences by income also existed in Austr alia, Canada and New Zealand. Those with below average incomes were more li kely to have not filled a prescription due to cost in Australia, Canada, Ne w Zealand and the US, with gaps by income most severe in the US. Ratings of quality of doctor visit were significantly different for the two income gr oups in the US, but not other countries. Conclusions: The analysis finds st riking differences among countries in the relative equity of health care ex periences. In general, care experiences are more unequal in three countries such as the US, Australia and New Zealand where systems have relatively gr eater reliance on private health insurance and markets. Greater inequality ill care experiences is also associated with more divided public opinion re garding the need for system reform and the direction of recent policy chang es. In Canada and Britain where care experiences are more equal, views of t he health system are similar across income groups. Reliance on private insu rance and patient user fees appears to lead to more divided views of the ov erall health system as well as inequity in access to care. (C) 2000 Elsevie r Science Ireland Ltd. All rights reserved.