Researchers examined the effect of Canada’s universal health insurance system, which covers most services with no out-of-pocket costs and is available to all Canadians, on the health of those citizens in lower socioeconomic groups. (Health Affairs Article) The researchers identified a cohort of Canadians who were free of cardiovascular disease at the initiation of the study period and followed their usage of health services and health status for ten years. They divided the cohort into socioeconomic groups according to income and education level, and looked at effects of age, race, gender and other factors, but only income and education level appeared to be relevant.
Outcomes included physician visits and other service use, development of cardiovascular disease, diabetes, and hypertension; as well as mortality. In general, as might be expected from prior research, those who were poorer and less educated were more distressed and depressed and had lower baseline health status and greater prevalence of risk factors for disease, including worse health behaviors. Universal health insurance worked in the sense that the lower socioeconomic groups actually used physicians more than the higher ones, so it would appear they had no access barriers. Notwithstanding this access to and utilization of care, the lower socioeconomic cohort had more disease and higher and earlier mortality. In fact, the higher of services was likely driven by their greater disease burden.
The lessons from this line of research are clear, but ignored by policymakers. People in lower socioeconomic groups often, if not usually, engage in poor health behaviors and are very unlikely to change those behaviors. Providing them with more free care to tend to the inevitable consequences of such poor health behaviors is not going to encourage them to take better care of themselves. Meanwhile they are placing an increasingly unsustainable burden on the rest of the population. It is well past time for much tougher measures to be taken. We have suggested before and now suggest again, people who won’t change poor health behaviors should simply not be eligible for public funding of health care. Referring to this group as universally “socioeconomically disadvantaged” implies that they got there through no fault of their own, but that is simply not true in most cases. There are people who were born with very limited intelligence or physical conditions which limit their ability to function; these people deserve all of society’s compassion and assistance. But the rest need to understand that they too must take responsibility for themselves and their health.