Health care access in three nations: Canada, insured America, and uninsured America

[Health behaviors and preventive tests in adults with and without health insurance in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil, 2003-2010]

This study analyzed indicators for health behaviors and use of preventive services in two probabilistic samples of adults, one in 2003 (n = 13,757) and the other in 2010 (n = 12,983), with and without private health insurance in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil. After adjusting for demographic variables, temporal variation, and source of care, there was a reduction in smoking prevalence, similar between individuals with and without private health insurance, from 2003 to 2010. During this same period the prevalence of excessive alcohol intake and sedentary lifestyle increased in both groups; with the same magnitude, there was a decrease in the prevalence of leisure-time physical activity. No changes were observed in the prevalence of blood pressure measurement, but the prevalence of cholesterol testing, mammogram, and Pap smear increased more sharply in individuals without health insurance.

Cost-related non-adherence to prescribed medicines among older adults: a cross-sectional analysis of a survey in 11 developed countries

OBJECTIVES

To assess the effects of costs on access to medicines in 11 developed countries offering different levels of prescription drug coverage for their populations.

DESIGN

Cross-sectional study of data from the Commonwealth Fund 2014 International Health Policy Survey of Older Adults.

SETTING

Telephone survey conducted in 11 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the USA.

PARTICIPANTS

22 532 adults aged 55 and older and living in the community in studied countries.

PRIMARY OUTCOME MEASURE

Self-reported cost-related non-adherence (CRNA) in the form of either not filling a prescription or skipping doses within the last 12 months because of out-of-pocket costs.

RESULTS

Estimated prevalence of CRNA among all older adults varied from <3% in the France, Norway, Sweden, Switzerland and the UK to 16.8% in the USA. Canada had the second highest national prevalence of CRNA (8.3%), followed by Australia (6.8%). Older adults in the USA were approximately six times more likely to report CRNA than older adults in the UK (adjusted OR=6.09; 95% CI 3.60 to 10.20). Older adults in Australia and Canada were also statistically significantly more likely to report CRNA than older adults in the UK. Across most countries, the prevalence of CRNA was higher among lower income residents and lower among residents over age 65.

CONCLUSIONS

Observed differences in national prevalence of CRNA appear to follow lines of availability of prescription drug coverage and the extent of direct patient charges for prescriptions under available drug plans.

Cost-related nonadherence to prescribed medicines among older Canadians in 2014: a cross-sectional analysis of a telephone survey

BACKGROUND

Canadians receive universal coverage for medically necessary hospital and physician services, but pharmaceutical coverage is incomplete. We sought to assess the effects of cost on access to medicines among older Canadians using data from a large survey conducted in 2014.

METHODS

This is a cross-sectional analysis of data from the Commonwealth Fund's 2014 International Health Policy Survey of Older Adults. Our primary outcome variable was self-reported cost-related nonadherence in the form of either not filling a prescription or skipping doses within the last 12 months because of out-of-pocket costs. We computed sample-weighted estimates of the population prevalence of cost-related nonadherence and conducted logistic regression analyses to determine associated factors.

RESULTS

We estimate that the prevalence of cost-related nonadherence in 2014 among Canadians aged 55 years and older was 8.3% (about 1 in 12). The population prevalence and adjusted odds of cost-related nonadherence was significantly higher among Canadians who were younger, in worse health, poorer or without private health insurance. Regional differences in population prevalence of cost-related nonadherence were not significant. The only provincial or regional difference in the adjusted odds of cost-related nonadherence was that residents of Quebec aged 55-64 years were about half as likely to report nonadherence as similarly aged residents of Ontario, our reference province (adjusted odds ratio 0.49, 95% confidence interval 0.29-0.82).

INTERPRETATION

The financial accessibility of prescription medicines still is a substantial public health issue in Canada that affects 1 in 12 Canadians older than 55 years of age. Older Canadians at greatest risk of cost-related nonadherence to prescribed treatments are those with low incomes and those without private insurance to cover costs not covered by public programs.

Universal prescription drug coverage in Canada: Long-promised yet undelivered

Canada's universal public healthcare system is unique among developed countries insofar as it does not include universal coverage of prescription drugs. Universal, public coverage of prescription drugs has been recommended by major national commissions in Canada dating back to the 1960s. It has not, however, been implemented. In this article, we extend research on the failure of early proposals for universal drug coverage in Canada to explain failures of calls for reform over the past 20 years. We describe the confluence of barriers to reform stemming from Canadian policy institutions, ideas held by federal policy-makers, and electoral incentives for necessary reforms. Though universal "pharmacare" is once again on the policy agenda in Canada, arguably at higher levels of policy discourse than ever before, the frequently recommended option of universal, public coverage of prescription drugs remains unlikely to be implemented without political leadership necessary to overcome these policy barriers.

Who are the under- and never-screened for cancer in Ontario: a qualitative investigation

BACKGROUND

Observed breast, cervical and colon cancer screening rates are below provincial targets for the province of Ontario, Canada. The populations who are under- or never-screened for these cancers have not been described at the Ontario provincial level. Our objective was to use qualitative methods of inquiry to explore who are the never- or under-screened populations of Ontario.

METHODS

Qualitative data were collected from two rounds of focus group discussions conducted in four communities selected using maps of screening rates by dissemination area. The communities selected were archetypical of the Ontario context: urban, suburban, small city and rural. The first phase of focus groups was with health service providers. The second phase of focus groups was with community members from the under- and never-screened population. Guided by a grounded theory methodology, data were collected and analyzed simultaneously to enable the core and related concepts about the under- and never-screened to emerge.

RESULTS

The core concept that emerged from the data is that the under- and never-screened populations of Ontario are characterized by diversity. Group level characteristics of the under- and never-screened included: 1) the uninsured (e.g., Old Order Mennonites and illegal immigrants); 2) sexual abuse survivors; 3) people in crisis; 4) immigrants; 5) men; and 6) individuals accessing traditional, alternative and complementary medicine for health and wellness. Under- and never-screened could have one or multiple group characteristics.

CONCLUSION

The under- and never-screened in Ontario comprise a diversity of groups. Heterogeneity within and intersectionality among under- and never-screened groups adds complexity to cancer screening participation and program planning.

Access to medical care: how do women in Canada and the United States compare?

OBJECTIVES

The purpose of this study is to determine if access to medical care and utilization of cancer screenings differs between women in the United States and Canada. This study examined this question by comparing women in Canada to women in the United States who have insurance coverage and those who do not.

METHOD

This study used data from the 2002/03 Joint Canada United States Survey of Health and examined access to medical care and cancer screenings. A binary probit model was used to address several measures of access to medical care and cancer screening utilization.

RESULTS

This study finds five significant differences between insured American and Canadian women. Canadian women are better off in terms of ever having a mammogram, having a regular doctor, and having access to needed medicine, but fare worse in terms of having had a recent mammogram and having perceived unmet healthcare needs. With the exception of having recent mammograms, there is no statistical difference between uninsured and insured American women.

CONCLUSION

Although this study does not show that one group is strictly better off, it does show that there are significant differences between the two groups of women.

The ethics and reality of rationing in medicine

Rationing is the allocation of scarce resources, which in health care necessarily entails withholding potentially beneficial treatments from some individuals. Rationing is unavoidable because need is limitless and resources are not. How rationing occurs is important because it not only affects individual lives but also expresses society's most important values. This article discusses the following topics: (1) the inevitability of rationing of social goods, including medical care; (2) types of rationing; (3) ethical principles and procedures for fair allocation; and (4) whether rationing ICU care to those near the end of life would result in substantial cost savings.

Access to primary and preventive care among foreign-born adults in Canada and the United States

OBJECTIVE

To conduct cross-country comparisons and assess the effect of foreign birth on access to primary and preventive care in Canada and the United States.

DATA SOURCES

Secondary data from the 2002 to 2003 Joint Canada-United States Survey of Health.

STUDY DESIGN

Descriptive and comparative analyses were conducted, and logistic regression models were used to assess the effect of immigrant status and country of residence on access to care. Outcomes included measures of health care systems and processes, utilization, and patient perceptions.

PRINCIPAL FINDINGS

In adjusted analyses, immigrants in Canada fared worse than nonimmigrants regarding having timely Pap tests; in the United States, immigrants fared worse for having a regular doctor and an annual consultation with a health professional. Immigrants in Canada had better access to care than immigrants in the United States; most of these differences were explained by differences in socioeconomic status and insurance coverage across the two countries. However, U.S. immigrants were more likely to have timely Pap tests than Canadian immigrants, even after adjusting for potential confounders.

CONCLUSIONS

In both countries, foreign-born populations had worse access to care than their native-born counterparts for some indicators but not others. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.

Systemic barriers to health care access for U.S. women with HIV: the role of cost and insurance

Lack of access to health care has particularly brutal consequences for low-income U.S. women with HIV who, without regular and consistent primary care, including treatment with highly active antiretroviral therapy (HAART), are less likely to live long and well with HIV. This article explores barriers to basic health care encountered by a sample of 55 HIV-infected women from urban and rural Wisconsin who participated in a longitudinal, qualitative study. In a series of 10 in-depth, story-eliciting interviews over a two-year period, each woman explained in detail what it was like for her to obtain health care since becoming infected. Conveying women's subjective experiences of trying to get the care they needed, their stories highlight serious institutional impediments to health care and provide a discomfiting glimpse of the systemic forces that limit access to health itself. Findings convey how the extraordinarily high cost of U.S. health care, the unpredictable and disjointed array of out-of-pocket costs, and the complex and obfuscated intricacies of health insurance impeded women's access. They lived a paradoxical reality: having an illness they feared, needing treatment for long-term survival, and being unable to meet its costs. Each woman's story reflects deep fissures in the U.S. health care system.

Cost-related prescription nonadherence in the United States and Canada: a system-level comparison using the 2007 International Health Policy Survey in Seven Countries

BACKGROUND

Prior research indicates that residents of the United States are nearly twice as likely as Canadian residents to report cost-related nonadherence (CRNA) (ie, being unable to fill > or =1 prescription due to cost). However, these kinds of national comparisons obscure important within-country differences in insurance coverage.

OBJECTIVE

This study was designed to compare rates of CRNA across major financing systems for prescription drugs in the United States and Canada.

METHODS

This study used the 2007 International Health Policy Survey in Seven Countries (supported by the US Commonwealth Fund) to estimate rates of CRNA in the following health systems: Canadian compulsory coverage (Quebec), Canadian senior and social assistance coverage (Ontario), Canadian income-based coverage (British Columbia, Manitoba, and Saskatchewan), Canadian mixed coverage (all other provinces), US private coverage (employer-based or individual insurance), US senior and social assistance coverage (Medicare and/or Medicaid), and US no coverage (uninsured).

RESULTS

Adults in the United States were far more likely than adults in Canada to report CRNA (23.1% vs 8.0%; chi(2) = 147.4; P < 0.001). Seniors (> or =65 years of age) were less likely than younger adults (<65 years) to report CRNA in both the United States (9.2% vs 25.8%; chi(2) = 64.3; P < 0.001) and Canada (4.6% vs 8.7%; chi(2) = 14.9; P < 0.001), presumably due to categorical eligibility for prescription drug insurance. Comparative analyses therefore focused on working-age adults (<65 years). Adults in Quebec (who have compulsory drug coverage) were only half as likely as those in Ontario to report CRNA (odds ratio [OR] = 0.5; 95% CI, 0.3-0.8). Uninsured adults in the United States were >7 times as likely to report CRNA (OR =7.2; 95% CI, 5.0-10.5), and adults with public insurance (OR = 2.2; 95% CI, 1.4-3.5) and private insurance (OR = 2.2; 95% CI, 1.6-3.0) were >2 times as likely to report CRNA.

CONCLUSIONS

After stratifying by age and simultaneously adjusting for sex, household income, and chronic illness, large differences in CRNA were found between and within countries. Even in a compulsory prescription insurance system like that in Quebec, 4.4% of working-age adults reported CRNA. However, these rates were low compared with CRNA rates for working-age adults in the United States who lack any health insurance (43.3%).

Is neighborhood access to health care provision associated with individual-level utilization and satisfaction?

OBJECTIVE

To explore whether travel time access to the nearest general practitioner (GP) surgery (which is equivalent to U.S. primary care physician [PCP] office) and pharmacy predicts individual-level health service utilization and satisfaction.

DATA SOURCES

GP and pharmacy addresses were obtained from the New Zealand Ministry of Health in 2003 and merged with a geographic boundaries data set. Travel times derived from these data were appended to the 2002/03 New Zealand Health Survey (N=12,529).

STUDY DESIGN

Multilevel logistic regression was used to model the relationship between travel time access and five health service outcomes: GP consultation, blood pressure test, cholesterol test, visit to pharmacy, and satisfaction with latest GP consultation.

DATA COLLECTION/EXTRACTION

Travel times between each census meshblock centroid and the nearest GP and pharmacy were calculated using Geographical Information System.

PRINCIPAL FINDINGS

When travel times were long, blood pressure tests were less likely in urban areas (odds ratio [OR] 0.75 [0.59-0.97]), GP consultations were less likely in rural centers (OR 0.42 [0.22-0.78]) and pharmacy visits were less likely in highly rural areas (OR 0.36 [0.13-0.99]). There was some evidence of lower utilization in rural areas.

CONCLUSIONS

Locational access to GP surgeries and pharmacies appears to sometimes be associated with health service use but not satisfaction.

Inquéritos Nacionais de Saúde: experiência acumulada e proposta para o inquérito de saúde brasileiro

As informações oriundas das fontes de dados secundários dos sistemas de informação em saúde existentes são fundamentais, mas insuficientes para responder às necessidades atuais da gestão do Sistema Único de Saúde na identificação dos problemas e necessidades de saúde da população brasileira. Os inquéritos populacionais são instrumentos utilizados como subsídios à formulação e avaliação das políticas públicas, tornando-se crescente a sua utilização nos diversos países como ferramenta de apoio ao planejamento em saúde. O artigo realiza uma breve revisão das iniciativas de realização de inquéritos no âmbito internacional e no Brasil, e propõe um roteiro para a realização do Inquérito Nacional de Saúde.