Universal care

Jon Gerrard observes that the expenditures we report¹ are lower than those reported by CIHI.² Our analysis is based on contacts that patients have with the health care system and includes only those costs that can be attributed to patients. When we discuss the appropriateness or potential impact of user fees or medical savings accounts, only these costs are relevant. CIHI² develops its “estimates” of public sector health expenditures on physicians and hospitals from diverse sources that were not relevant to our analysis. CIHI data on total public health expenditures include not just hospital and physician spending but also expenditures on drugs, other professionals (such as chiropractors and optometrists), public health, home care, health research and other aspects of health care.

Although most physician costs are captured in our analysis, the costs we report are smaller than the CIHI figures for at least one reason that we can identify: costs for salaried physicians who work in some hospital units (e.g., some radiology departments, emergency rooms and intensive care units) were not captured. This underreporting is a limitation, but there is no reason to assume that it distorted the results of our analysis. Of the Winnipeg family physician workforce, only 7% are salaried physicians, most of whose activity is reported through evaluation claims; thus, little activity of this key group (family physicians as a whole) is missed in our analysis.

Our hospital costs are smaller than those reported by CIHI for several reasons. Building capital costs are omitted from our calculations, and we do not report costs associated with educational programs offered in hospitals. We do include costs of ordinary overhead (for example housekeeping and meal costs) that can be assigned to patients in particular units.

We agree with Ross McElroy that the analyses suggest that medical savings accounts and user fees do not make sense and inappropriately target the poor and the sick. However, we do not believe that universal medical care is responsible for physicians ordering unnecessary tests or for unnecessary referrals. The United States with its millions of uninsured is an example of a developed country without universal insurance that holds the record for unnecessary medical expenditures in the name of avoiding legal liability.

Chris Delaney and Jacqueline Quail suggest that poor access to medical care may explain the poorer health status of people with lower socioeconomic status. We know that preventive services such as Papanicolaou smears and flu shots are underdelivered to this segment of the population. However, it is not clear if increased investment in health care is the answer. Alter and colleagues³ recently demonstrated that although higher-income Ontario residents saw more cardiologists, received more cardiac rehabilitation and underwent more coronary angiography after myocardial infarction than did low-income residents, their outcomes at 1 year were no better. Labonte⁴ estimated in 1992 that for the $350 million increase that Ontario hospitals received that year, the province could have funded 70 000 more rent-geared-to-income housing units, 450 000 more subsidized daycare spaces, and 12 000 transitional shelter beds. We really don't know which would have been the better investment in improving health for low-income residents.

Noralou P. Roos Evelyn Forget Department of Community Health Sciences University of Manitoba Winnipeg, Man.