A tale of three countries: How access to surgeries differs by income across health systems
Advocates of single-payer health care in the US argue that having a public health care system would provide low-income patients with similar access to complex care (like surgeries) as high-income patients. Another potential benefit to a public health system is greater accountability for reducing low-value care (if the government is paying for health care, they will likely scrutinize the effectiveness of procedures more intensely).
However, there has been little research on whether countries with public or private health systems differ in how they provide surgical procedures to patients of various income levels. In their new paper in JAMA Open, University of Toronto medical student Hilary Y. M. Pang, Lown Institute data scientist Kelsey Chalmers, director of the Centre for Health Policy at the University of Melbourne Adam Elshaug, and colleagues explore this topic by looking at differences in utilization of certain cancer procedures across income levels in Ontario, New South Wales, and New York State.
(This research was funded in part by Arnold Ventures, and is part of a series of papers on low-value services led by Elshaug and Chalmers, in partnership with the Lown Institute.)
Using an international approach allowed the researchers to compare utilization across different types of health care systems: Canada only has public health insurance, which covers everyone; Australia has public insurance for all, but also has supplemental private insurance available; and the US relies on private health insurance for younger adults, which leaves millions uncovered. The researchers looked at three common cancer surgeries: pancreatectomy (removal of the pancreas), nephrectomy (removal of the kidney), and radical prostatectomy (removal of all or part of the prostate gland).
They found that overall, all three surgeries were done more in the US and Australia, compared to Canada. In all three locations, residents of high-income neighborhoods were more likely to get all three surgeries — although the gap between low- and high- income patient utilization was smallest in Ontario.
“Our findings highlight how countries’ health care systems can exacerbate or alleviate wealth-based differences in access to surgical procedures.”Pang, Chalmers, et al. JAMA Open, 2021
This has important implications for both underuse and overuse of cancer surgeries across health systems. For pancreatic and kidney cancer, surgery is one of the only treatment options, so if low-income patients in the US and Australia have trouble accessing these surgeries, that will exacerbate health disparities. And the fact that Canadians of all incomes had less access to these surgeries shows that wait times for elective procedures may be a tradeoff for universal coverage.
For prostate cancer, watchful waiting and radiation are other potential treatment options, so higher rates among high-income people in the US and Australia may indicate that these patients are at risk of overuse.
“These findings suggest that income-based disparities are larger in the United States and Australia and smaller in Canada and highlight trade-offs inherent in the health care systems of different countries,” the authors write.
For more on this research, read the full paper in JAMA Network Open!