Authors David A. Alter, Therese Stukel, et. al. demonstrated in Health Affairs this month that lower socioeconomic status in Canada is related to lower health status, even with good access to health care services. If poor access to health care were the main cause of lower health status, then universal access should eliminate a lot of the problem. The authors studied 14,800 patients with generally unlimited access to primary and specialty care across Canada's universal health care system. The cohort of patients studied was initially free of heart disease, but after tracking them for more than ten years, these patients had comparably higher rates of CV morbidity and mortality. They found that low income patients used more health care services than their counterparts with higher incomes and education. But disturbingly, they basically found that despite increased use of health care services, patients with lower incomes and education levels had still had poorer health outcomes and higher mortality.

The take home lesson for us in the U.S. appears to be that we should not presume that expanded access to care will of itself eliminate historical disparities among at-risk groups. The authors felt that universal access does reduce some disparities. They are, however, suggesting that major national lifestyle and behavioral prevention programs will be necessary to actually improve health status in these populations. One other point, they were not using registries to give the doctors of these patients continuous feedback as the ACC is suggesting in U.S. health reform as a powerful way to systematically reduce disparities.

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