Schoen Cathy, Doty Michelle M
Health Policy, Research and Evaluation, The Commonwealth Fund, One East 75th Street, New York, NY 10021, USA.
Health Policy. 2004 Mar;67(3):309-22. doi: 10.1016/j.healthpol.2003.09.006.
To examine across five countries inequities in access to health care and quality of care experiences associated with income, and to determine whether these inequities persist after controlling for the effect of insurance coverage, minority and immigration status, health and other important co-factors.
Multivariate analysis of a cross-sectional 2001 random survey of 1400 adults in five countries: Australia, Canada, New Zealand, United Kingdom, and United States.
Access difficulties and waiting times, cost-related access problems, and ratings of physicians and quality of care.
The study finds wide and significant disparities in access and care experience between US adults with above and below-average incomes that persist after controlling for insurance coverage, race/ethnicity, immigration status, and other important factors. In contrast, differences in UK by income were rare. There were also few significant access differences by income in Australia; yet, compared to UK, Australians were more likely to report out of pocket costs. New Zealand and Canada results fell in the mid-range of the five nations, with income gaps most pronounced on services less well covered by national systems. In the four countries with universal coverage, adults with above-average income were more likely to have private supplemental insurance. Having private insurance in Australia, Canada, and New Zealand protects adults from cost-related access problems. In contrast, in UK having supplemental coverage makes little significant difference for access measures. Being uninsured in US has significant negative consequences for access and quality ratings.
For policy leaders, the five-nation survey demonstrates that some health systems are better able to minimize among low income adults financial barriers to access and quality care. However, the reliance on private coverage to supplement public coverage in Australia, Canada, and New Zealand can result in access inequities even within health systems that provide basic health coverage for all. If private insurance can circumvent queues or waiting times, low income adults may also be at higher risks for non-financial barriers since they are less likely to have supplemental coverage. Furthermore, greater inequality in care experiences by income is associated with more divided public views of the need for system reform. This finding was particularly striking in Canada where an increased incidence of disparities by income in 2001 compared to a 1998 survey was associated with diverging views in 2001.
考察五个国家中与收入相关的医疗保健可及性和医疗服务体验质量方面的不平等情况，并确定在控制了保险覆盖范围、少数族裔和移民身份、健康状况及其他重要共同因素的影响后，这些不平等是否依然存在。
对2001年在澳大利亚、加拿大、新西兰、英国和美国这五个国家对1400名成年人进行的横断面随机调查进行多变量分析。
就医困难和等待时间、与费用相关的就医问题以及对医生和医疗服务质量的评分。
研究发现，美国收入高于平均水平和低于平均水平的成年人在医疗可及性和服务体验方面存在广泛且显著的差异，在控制了保险覆盖范围、种族/族裔、移民身份及其他重要因素后，这些差异依然存在。相比之下，英国按收入划分的差异很少见。澳大利亚按收入划分的显著就医差异也很少；然而，与英国相比，澳大利亚人更有可能报告自付费用。新西兰和加拿大的结果处于五个国家的中间范围，在国家体系覆盖较差的服务方面，收入差距最为明显。在四个有全民医保的国家中，收入高于平均水平的成年人更有可能拥有私人补充保险。在澳大利亚、加拿大和新西兰，拥有私人保险可使成年人免受与费用相关的就医问题困扰。相比之下，在英国，拥有补充保险对就医措施几乎没有显著影响。在美国，未参保对就医可及性和质量评分有重大负面影响。
对于政策制定者而言，这项五国调查表明，一些医疗体系更有能力尽量减少低收入成年人在获得医疗服务和高质量医疗方面的经济障碍。然而，在澳大利亚、加拿大和新西兰，依赖私人保险来补充公共保险可能导致即使在为所有人提供基本医疗保险的医疗体系内也存在就医不平等。如果私人保险可以避免排队或等待时间，低收入成年人也可能面临更高的非经济障碍风险，因为他们不太可能拥有补充保险。此外，收入方面在医疗服务体验上的更大不平等与公众对医疗体系改革必要性的意见分歧更大有关。这一发现在加拿大尤为显著，与1998年的调查相比，2001年收入差距发生率的增加与2001年意见分歧的扩大有关。
