Melissa Raven from PHC RIS provides this useful summary of a Canadian study into factors influencing access to health care. The paper stops short of recommending strategies to address its finding of reduced access for people from lower socio-economic groups but Croakey boldly suggests it makes a good case for a ‘low SES’ loading for Medicare rebates – similar to the rural loading that currently exists.
It is well established that many people from lower socioeconomic groups have inadequate access to healthcare. In the Canadian province of Ontario, Michelle Olah and colleagues from the Centre for Research on Inner City Health investigated the influence of perceived socioeconomic status on access to primary medical care. In this well designed study, one female researcher and a male counterpart were randomly assigned to telephone the offices of 375 randomly selected Toronto family physicians and general practitioners, seeking appointments as new patients. Also randomised were high versus low socioeconomic status (revealed verbally by referring to ‘my welfare worker’ and in responses to routine questions) and presence or absence of chronic health conditions (diabetes and back pain).
In Ontario, all residents have health insurance coverage provided by a single public insurer, with no patient co-payments, so doctors are reimbursed the same regardless of patients’ socioeconomic status. Consequently, this study was able to investigate the influence of perceived socioeconomic status separately from differential reimbursement incentives.
The results confirmed the authors’ expectations: prospective patients portrayed as higher socioeconomic status were significantly more likely to receive an unconditional offer of an appointment. Chronic health conditions also significantly increased the likelihood of appointments, independently of socioeconomic status.
The most common justification for not offering an appointment was that the doctor was not accepting new patients. According to Statistics Canada (2011), 15% of Canadians did not have a regular doctor in 2010, and the main reason reported by those who had tried unsuccessfully to find one was that local doctors were not accepting new patients. This suggests that discrimination on the basis of socioeconomic status may be a major contributor to the problem. However, Olah and her colleagues acknowledged that their study was unable to distinguish between socioeconomic discrimination and welfare-status discrimination.
Access to healthcare is of course only one channel through which disadvantage and discrimination can impact on health; many of the effects of social determinants of health act more directly on health, for example through food insecurity and inadequate housing. However, lack of access to primary medical care is a significant barrier to good health.
Surprisingly, the authors did not mention the inverse care law. The findings support the main claim of Julian Tudor Hart’s theory, that ‘availability of good medical care tends to vary inversely with the need for the population served’ (p. 1), but not his contention that this pattern of inequality is driven by profit.