Disability in two health care systems: access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities

BackgroundAn overarching question in health policy concerns whether the current mix of public and private health coverage in the United States can be, in one way or another, expanded to include all persons as it does in Canada. As typically high-end consumers of health care services, people with disabilities are key stakeholders to consider in this debate. The risk is that ways to cover more persons may be found only by sacrificing the quantity or quality of care on which people with disabilities so frequently depend. Yet, despite the many comparisons made of Canadian and U.S. health care, few focus directly on the needs of people with disabilities or the uninsured among them in the United States. This research is intended to address these gaps. Given this background, we compare the health care experiences of working-age uninsured and insured Americans with Canadian individuals (all of whom, insured) with a special focus on disability. Two questions for research guide our inquiry: (1) On the basis of disability severity level and health insurance status, are there differences in self-reported measures of access, utilization, satisfaction with, or quality of health care services within or between the United States and Canada? (2) After controlling covariates, when examining each level of disability severity, are there any significant differences in these measures of access, utilization, satisfaction, or quality between U.S. insured and Canadian persons?MethodsCross-sectional data from the Joint Canada/United States Survey of Health (JCUSH) are analyzed with particular attention to disability severity level (none, nonsevere, or severe) among three analytic groups of working age residents (insured Americans, uninsured Americans, and Canadians). Differences in three measures of access, one measure of satisfaction with care, one quality of care measure, and two varieties of physician contacts are compared. Multivariate methods are then used to compare the healthcare experiences of insured U.S. and Canadian persons on the basis of disability level while controlling covariates.ResultsIn covariate-controlled comparisons of insured Americans and Canadians, we find that people with disabilities report higher levels of unmet need than do their counterparts without disabilities, with no difference in this result between the nations. Our findings on access to medications and satisfaction with care among people with disabilities are similar, suggesting worse outcomes for people with disabilities, but few differences between insured U.S. and Canadian individuals. Generally, we find higher percentages who report having a regular physician, and higher contact rates with physicians among people with disabilities than among people without them in both countries. We find no evidence that total physician contacts are restricted in Canada relative to insured Americans at any of the disability levels. Yet we do find that quality ratings are lower among Canadian respondents than among insured Americans. However, bivariate estimates on access, satisfaction, quality, and physician contacts reveal particularly poor outcomes for uninsured persons with severe disabilities in the United States. For example, almost 40% do not report having a regular physician, 65% report that they need at least one medication that they cannot afford, 45% are not satisfied with the way their care is provided, 40% rate the overall quality of their care as fair or poor, and significant reductions in contacts with two types of physicians are evident within this group as well.ConclusionBased on these results, we find evidence of disparities in health care on the basis of disability in both Canada and the United States. However, despite the fact that Canada makes health insurance coverage available to all residents, we find few significant reductions in access, satisfaction or physician contacts among Canadians with disabilities relative to their insured American counterparts. These results place a spotlight on the experiences of uninsured persons with disabilities in America and suggest further avenues for research.     

Immigrant status and unmet health care needs

OBJECTIVES: To compare whether unmet health needs differ between immigrants and non-immigrants, and examine whether help-seeking characteristics account for any unmet needs disparities. METHODS: The data are from the Canadian Community Health Survey Cycle 1.1, conducted by Statistics Canada in 2000-2001. The study sample includes 16,046 immigrants and 102,173 non-immigrants aged 18 and older from across Canada. The study employs logistic regression models to examine whether help-seeking behaviours explain unmet needs differences. RESULTS: Logistic regression analysis indicates that immigrants have a 12% (95% CI: 6-18) lower all-cause unmet needs risk (odds ratio) than non-immigrants after controlling for differences in help-seeking characteristics. The unmet needs risk among long-term immigrants (15 years of residence and more), however, is similar to non-immigrants after considering these characteristics. We found differences between immigrants and non-immigrants in reasons for unmet needs, with more immigrants believing that the care would be inadequate, not knowing where to access health care, and having foreign language problems. CONCLUSIONS: The Canadian health care system delivers sufficient health care to immigrants, even though the poverty rate and proportion of visible minorities are comparatively higher within this subpopulation. Nonetheless, these results indicate that some immigrant-specific health care access barriers may exist.     

Comparing health and health care use in Canada and the United States

Results from the Joint Canada/United States Survey of Health (2002-2003) reveal that health status is relatively similar in the two countries, but income-related health disparities exist. Americans in the poorest income quintile are more likely to have poor health than their Canadian counterparts; there were no differences between the rich. In general, Canadians were more like insured Americans regarding access to services, and Canadians experienced fewer unmet needs overall. Despite higher U.S. levels of spending on health care, residents in the two countries have similar health status and access to care, although there are higher levels of inequality in the United States.     

Left out: immigrants' access to health care and insurance

Recent policy changes have limited immigrants' access to insurance and to health care. Fewer noncitizen immigrants and their children (even U.S.-born) have Medicaid or job-based insurance, and many more are uninsured than is the case with native citizens or children of citizens. Noncitizens and their children also have worse access to both regular ambulatory and emergency care, even when insured. Immigration status is an important component of racial and ethnic disparities in insurance coverage and access to care.     

Effects of length of stay and language proficiency on health care experiences among immigrants in Canada and the United States

This study sought to examine the influence of length of stay and language proficiency on immigrants' access to and utilization of care in Canada and the United States (U.S,). Data came from the 2007-2008 Canadian Community Health Survey and the National Health Interview Survey. Analyses were limited to foreign-born, non-elderly adults in each country (n = 12,870 in Canada and n = 7440 in the U.S.). Health care indicators included having a usual source of care; annual consultation with a health professional, dentist, and eye doctor; flu shot in the past year; and Pap test in the past 3 years. Logistic regression models were employed to estimate the relative odds of access or use of care, adjusting for need, demographic factors, socioeconomic status, and insurance coverage. In general, rates of health care access and utilization were higher in Canada than the U.S. among all immigrant groups. In both countries, adjusted analyses indicated that immigrants with shorter length of stay (less than 10 years) and limited language proficiency generally had lower rates of access/use compared with those with longer length of stay (10 years or more) and proficiency in each country's official language(s), respectively. There was one exception to this pattern in the U.S.: immigrants with limited English had higher odds of having a recent Pap test relative to English-proficient immigrants. The persistence of disparities in health care experiences based on length of stay and language proficiency in Canada suggests that universal health insurance coverage may not be sufficient for ensuring access to and utilization of primary and preventive care for this population.     

The insurance gap and minority health care, 1997-2001

Gaps in access to medical care among working-age white Americans, African Americans and Latinos failed to improve between 1997 and 2001, despite a booming economy and increased national attention to narrowing and eliminating minority health disparities. African Americans and Latinos continue to have less access to a regular health care provider, see a doctor less often and lag behind whites in seeing specialists, according to recent findings from the Center for Studying Health System Change (HSC). Ethnic and racial disparities in access among uninsured Americans are much greater than disparities among the insured. Uninsured whites' greater financial resources may explain why they have fewer problems accessing care. Eliminating disparities in minority health care will be difficult without first eliminating these gaps in minority health insurance.     

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

This analysis provides new statistics for one of the oldest and fiercest debates in American health policy: whose residents have better access to health care, the United States' or Canada's? Data from the 2002-2003 Joint Canada U.S. Survey of Health show that, despite major differences in their health systems, most Canadians and Americans get the care they need. However, one group of Americans is much more likely to report serious access barriers--the uninsured. About one-third of currently or recently uninsured Americans, aged 18 to 64, said they could not get needed health care (over three times the rate of insured Americans or Canadians). Compared with Canadians and insured Americans, the uninsured are less likely to use hospital or physician services, and those who do are less satisfied with the care they receive. They are also less likely to purchase prescribed medications, due to cost. From a consumer perspective, the most salient feature of the Canadian system is its universality. In contrast, insured Americans under age 65 are at risk of losing their insurance and facing substantial access barriers.     

Children’s Receipt of Health Care Services and Family Health Insurance Patterns

PURPOSE Insured children in the United States have better access to health care services; less is known about how parental coverage affects children’s access to care. We examined the association between parent-child health insurance coverage patterns and children’s access to health care and preventive counseling services.METHODS We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002–2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children’s unmet health care and preventive counseling needs.RESULTS Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02–2.97), no usual source of care (OR = 1.31; 95% CI, 1.10–1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01–1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04–1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities.CONCLUSIONS Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.     

Overcoming the Odds: Access to Care for Immigrant Children in Working Poor Families in California

Objectives: To explore the extent to which, among working poor families, uninsured immigrant children experience more barriers to care than uninsured nonimmigrants, and compare these differences to those of insured children. Methods: We used data from the 2001 California Health Interview Survey, a randomized, population-based telephone survey conducted from November 2000 through September 2001. Financial and nonfinancial access to health care and utilization of health services were examined for 3,978 nonimmigrant and 462 immigrant children and adolescents under the age of 18 years. We compared differences in crude rates across four subgroups (insured immigrants, uninsured immigrants, insured nonimmigrants, uninsured nonimmigrants) and in adjusted models controlling for socioeconomic and immigration characteristics, parental language, health status, and other demographic factors. Results: More immigrant than nonimmigrant children lacked health insurance at the time of the interview (44% vs. 17%, p < 0.0001). Among the uninsured, immigrants had higher odds of perceiving discrimination (11% vs. 5%, p < 0.05) and postponing emergency room (ER) (16% vs. 7%, p < 0.05) and dental care (40% vs. 30%, p < 0.05) after controlling for covariates. Among the insured, immigrants fared worse on almost every access and utilization outcome. Among insured immigrants, child and parent undocumented status and having a non-English-speaking parent contributed to missed physician and ER visits. Conclusions: Disparities in access and use remain for immigrant poor children despite public insurance eligibility expansions. Insurance does not guarantee equitable health care access and use for undocumented children. Financial and nonfinancial barriers to health care for immigrant children must be removed if we are to address disparities among minority children.     

The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States

BACKGROUND: Nearly half of recent immigrants to the United States lack health insurance. Access to cancer screening services for this group is problematic. We examine the role of health insurance and having a usual source of care (USC) on Pap smear and mammography utilization by immigrant women using a nationally representative sample. METHODS: We used a telephone survey that oversampled racial and ethnic minorities. We analyzed data on 3,622 women age 18-70. We classified the 822 foreign-born women as recent immigrants if they had resided in the United States for under 10 years; LT immigrants were those with a longer tenure. RESULTS: Among recent immigrants, 73% and 78% (SE 4%) reported a Pap smear or mammogram, respectively, in the previous 2 years versus 89% and 89% of U.S.-born women (P < 0.05 for both comparisons). Among those with insurance or a USC, differences in screening between recent immigrants and U.S.-born women were four percentage points or less and not statistically significant. However, uninsured recent immigrants were less likely than uninsured U.S.-born women to have Pap smears [60% (SE 7%) versus 71%, P < 0.05]. Adjusting for differences in sociodemographics, health attitudes or beliefs, patient or provider communication, and the medical care environment, insurance remained the strongest predictor of screening. CONCLUSION: Disparities in screening were greatly attenuated among the insured population. Increasing awareness of available safety net sources of care may also improve cancer screening among uninsured recent immigrants.     

The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care

OBJECTIVE: To examine the extent to which health insurance coverage and available safety net resources reduced racial and ethnic disparities in access to care. DATA SOURCES: Nationally representative sample of 11,692 African American, 10,325 Hispanic, and 74,397 white persons. Nonelderly persons with public or private health insurance and those who were uninsured. STUDY DESIGN: Two cross-sectional surveys of households conducted during 1996-1997 and 1998-1999. DATA COLLECTION: Commonly used measures of access to and utilization of medical care were constructed for individuals. These measures include the following. (1) percent reporting unmet medical needs, (2) percent without a regular health care provider, and (3) no visit with a physician in the past year. FINDINGS: More than 6.5 percent of Hispanic and African Americans reported having unmet medical needs compared to less than 5.6 percent of white Americans. Hispanics were least likely to see the same doctor at their usual source of care (59 percent), compared to African Americans (66 percent) and whites (75 percent). Similarly, Hispanics were less likely than either African Americans or whites to have seen a doctor in the last year (65 percent compared to 76 percent or 79 percent). For Hispanics, more than 80 percent of the difference from whites was due to differences in measured characteristics (e.g., insurance coverage, income, and available safety net services). Differences in measured characteristics between African Americans and whites explained less than 80 percent of the access disparities. CONCLUSION: Lack of health insurance was the single most important factor in white-Hispanic differences for all three measures and for two of the white-African American differences. Income differences were the second most important factor, with one exception. Community characteristics generally were much less important, with one exception. The positive effects of insurance coverage in reducing disparities outweigh benefits of increasing physician charity care or access to emergency rooms.     

Hispanic-Asian Immigrant Inequality in Perceived Medical Need and Access to Regular Physician Care

In the face of continuing large immigrant streams, Hispanic and Asian immigrants’ human and social capital inequalities will heighten U.S. race/ethnic health and health care disparities. Using data from the 2004 and 2008 panels of the Survey of Income and Program Participation, this study assessed Hispanic-Asian immigrant disparity in access to health care, measured by perceived medical need and regular access to a physician. Logistic regression results indicated that Hispanics had lower perceived met medical need and were less likely to see a doctor regularly. These disparities were significantly attenuated by education and health insurance. Assimilation-related characteristics were significantly associated with a regular doctor visit and were not fully mediated by socioeconomic variables. Findings indicate the importance of education above and beyond insurance coverage for access to health care and suggest the potential for public health efforts to improve preventive care among immigrants.     

Children's ability to access and use health care

Under new regulations for Medicaid and the State Children's Health Insurance Program (SCHIP), states can extend health insurance to child enrollees' uninsured parents. We compared the extent to which child-only and family coverage (child and parent insured) ensure health care access and use for children in working-poor families. Among these children, 21 percent were uninsured, as were 30 percent of their parents. Children with no family coverage encountered more access barriers than insured children. Extending insurance to children markedly increases access and use. The additional benefits of family coverage over child-only coverage seem less pronounced, but family coverage expansions may narrow disparities in access.     

Comparing social determinants of self-rated health across the United States and Canada

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research-Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ-gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries-the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.     

Children''s Health Insurance Status, Access to and Utilization of Health Services, and Unmet Health Needs in a Rural Alabama School System

PURPOSE: This study examines the relationship between children's health insurance status and utilization of health services, establishment of a medical home, and unmet health needs over a 3-year period (1996-1998) in a rural Alabama K-12 school system. METHODS: As part of a children's health insurance outreach program, questionnaires were administered to parents of 754 children regarding health and health care access. In addition, noninvasive head-to-toe physical assessments of children were conducted on-site at 4 schools. FINDINGS: A relationship between health care utilization and insurance status was observed. Results found that insured children had 1.183 (P < .0115) times the number of medical visits as uninsured children. Among uninsured children, the time since last dental visit was 1.6 (P < .001) times longer than that of insured children. Also, insured children were 5.21 times more likely than uninsured (P < .0001) to report having a medical home. No significant differences between insured and uninsured children were found regarding unmet health needs as measured by referrals made after the children's physical assessments. CONCLUSIONS: Child health coverage is an important determining factor in the ability of families to access and utilize health care services. These findings have implications for populations in similar rural communities across the nation.     

Uninsured vs. insured population: variations among nonelderly Americans

This study identified the underlying demographic and socioeconomic factors associated with insurance status among nonelderly Americans (age 19-64), as well as compared health care utilization between insured and uninsured. Data from the Community Tracking Study 1996-1997 Household Survey were analyzed. Approximately 74 percent of uninsured Americans are nonelderly Americans. Among the nonelderly Americans, about 17 percent are uninsured. Our findings show that insurance status varies significantly by region, age, race, gender, marital status, income, education, employment status, and health status. Also, the insured nonelderly Americans were found to have better access to health care than the uninsured nonelderly.     

The role of health insurance coverage in reducing racial/ethnic disparities in health care

Research showing racial/ethnic disparities in medical care obtained by people with comparable insurance has raised questions about the extent to which health insurance improves opportunities for care. To assess whether insurance expansions could be expected to reduce racial/ethnic disparities in access to care, this paper reviews evidence from studies specifically designed to quantify the contribution of health insurance to racial/ethnic disparities in access. The studies provide evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.     

Emergency Room Visits by Uninsured Child and Adult Residents in Ontario,Canada: What Diagnoses,Severity and Visit Disposition Reveal About the Impact of Being Uninsured

Canadian immigrants can be without health insurance for many reasons but limited data exists regarding uninsured health outcomes. Uninsured Canadian residents were identified in the National Ambulatory Care Reporting System for all visits to emergency departments in Ontario, Canada between 2002/3 and 2010/11 (N = 44,489,750). Frequencies for main diagnoses, severity (triage), and visit disposition were compared. Ambulatory care sensitive conditions were identified in a 10 % subsample. The uninsured (N = 140,730; 0.32 %) were more likely to be diagnosed with mental health (insured: 3.48 %; uninsured: 10.47 %) or obstetric problems (insured: 2.69 %; uninsured: 5.56 %), be triaged into the two most severe categories (insured: 11.2 %; uninsured 15.6 %), leave untreated (insured: 3.1 %; uninsured: 5.4 %), or die (insured: 2.8 %; uninsured: 3.7 %). More ACSC visits were made by uninsured children and youth. Insurance status is associated with more serious health status on arrival to emergency departments and more negative visit outcomes.     

Unmet health care and health care utilization

The objective of this study is to examine the causal effect of health care utilization on unmet health care needs. An IV approach deals with the endogeneity between the use of health care services and unmet health care, using the presence of drug insurance and the number of physicians by health region as instruments. We employ three cycles of the Canadian Community Health Survey confidential master files (2003, 2005, and 2014). We find a robustly negative relationship between health care use and unmet health care needs. One more visit to a medical doctor on average decreases the probability of reporting unmet health care needs by 0.014 points. The effect is negative for the women‐only group whereas it is statistically insignificant for men; similarly, the effect is negative for urban dwellers but insignificant for rural ones. Health care use reduces the likelihood of reporting unmet health care. Policies that encourage the use of health care services, like increasing the coverage of public drug insurance and increasing after hours accessibility of physicians, can help reduce the likelihood of unmet health care.     

Community-Level Uninsurance and the Unmet Medical Needs of Insured and Uninsured Adults

Objective. To examine the relationship between community-level uninsurance rates and the self-reported unmet medical needs of insured and uninsured adults in the U.S.
Data Sources. 2000–2001 Community Tracking Study, which includes data from 60 randomly selected U.S. communities. The sample is representative of the contiguous U.S. states.
Study Design. Multilevel logistic regressions were employed to investigate whether the local uninsurance rate was related to having reported unmet medical needs within the last year. The models also included individual and community variables that could be potentially related to both community uninsurance rates and having reported unmet medical needs.
Principal Findings. The community uninsurance rate was positively associated with having reported unmet medical needs, but only for insured adults. On average, a five percentage point increment in the local uninsured population is associated with a 10.5 percent increase in the likelihood that an insured adult will report having unmet medical needs during the 12-month period studied.
Conclusion. Local health care delivery systems seem to be negatively affected by high uninsurance rates. These effects could have negative consequences for health care access, even for individuals who are themselves insured.