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

https://doi.org/10.1016/j.dhjo.2008.07.006Get rights and content

Abstract

Background

An 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?

Methods

Cross-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.

Results

In 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.

Conclusion

Based 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.

Section snippets

Questions for Research

Given the issues just described, a series of analyses are conducted to compare the health care experiences of working-age uninsured and insured Americans with Canadian working-age individuals (all of whom are insured). Quantitative data from the Joint Canada/United States Survey of Health (JCUSH) are analyzed, and two questions for research guide the inquiry:

  • 1.

    On the basis of disability severity level and health insurance status, are there differences in self-reported measures of access,

Survey data

The JCUSH, which was conducted jointly by the U.S. National Center for Health Statistics (NCHS) and Statistics Canada, provides nationally representative, cross-sectional data on Canadian and American household residents aged 18 years or older. Administered between November 2002 and June 2003, the survey excludes members of the armed forces and institutionalized persons in both nations, and persons without a landline telephone in the household. Households were drawn through random digit dialing

Disability, overall health, insurance coverage, and demographics in the United States and Canada

In Table 1, four views of the working-age population are provided by country and by disability level. Distributions on two important variables, overall health and U.S. insurance status, are also provided. In the United States, there are an estimated 21.2 million working-age persons with nonsevere disabilities (about 12% of the 173.4 million working-age persons overall) and another 16.6 million persons with severe disabilities (about 10% of the total). In Canada, there are an estimated 2.3

Discussion and Study Limitations

Working-age people with disabilities in Canada and the United States have much in common. The percentage reporting disability is quite similar, even after standardizing for age. In both nations, overall health is significantly worse among people with disabilities than among people without them, particularly for those with severe disabilities. In Canada and the United States alike, the need for services from physicians expands greatly with the increasing severity of disability. Yet, while all

Acknowledgments

We gratefully acknowledge the project assistance we received from Jane Gentleman, Peter Meyer, Elizabeth Rasch and Catherine Simile. We particularly wish to thank Jane Gentleman, Debra Blackwell, Michael Martinez and Jennifer Madans for their extensive notes and substantive suggestions on earlier drafts of this paper. In addition, the critiques we received from the peer reviewers at the Disability and Health Journal were invaluable to us.

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    Financial disclosure: Funds for these analyses were generously provided by contract with the National Center for Health Statistics, Centers for Disease Control and Prevention (NCHS/CDC). The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the NCHS/CDC. This paper was also required to clear internal review at NCHS/CDC. These relationships, and this review process, did not restrict either author from developing the research questions, conducting the analyses, or presenting the results in an unbiased fashion, and in the authors’ opinions, lessened the possibility of bias in this manuscript. Both authors are unaware of any further financial or other relationships affecting this work.

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