The 3,505 Canadians sampled in this study were divided, upon the basis of house holdincome, into five quintiles. The participants were then asked to rate their health as either excellent, very good, good, fair, or poor. The participants also reported the presence of a severe mobility problem and any unmet health care needs. Figure 7.1 shows the percentage of respondents, by income quintile, providing a fair or poor response, a mobility restriction, and unmet health care needs. Findings are consistent with numerous other studies that show that income level is a strong predictor of reported health status. Canadians within the lowest income quintile reported the greatest likelihood of fair or poor health, of having a severe motor mobility, and of having an unmet health care need. This survey did not assess frequency and type of health services used, but other Canadian studies have addressed this issue.

Glazier and colleagues carried out an analysis of hospital use from 1990 to 1992 in Southeast Toronto and examined whether such use was related to income (Glazier, Badley, Gilbert, and Rothman, 2000). The researchers classified the 28 census tracts in this area into one of five quintiles based on the median household income of the area. They then examined a number of indicators of hospital use. The percentage of households identified, by using Statistics Canada’s Low Income cut-off s, as being of low income was 12% in the richest quintile, 19% in the second quintile, 23% in the middle quintile, 30% in the second-lowest quintile, and 50% in the lowest income quintile. Table 7.2 provides findings concerning differential hospital use and cost for those found in the five different income quintiles. The number of individuals admitted to hospital, actual number of total admissions, and health care costs were highest among those living in the lowest income quintile. These findings are consistent with a large number of findings from Canadian studies.

Roos and Mustard (1997) carried out a very extensive study of health care utilization among 600,000 residents of Winnipeg that assessed whether primary care and specialist services were equally likely to be accessed by Canadians of different incomes. Enumeration areas of approximately 700 people were classified, based on median income, into one of five income quintiles. Table 7.3 shows that income quintile was also related to a number of other indicators such as female-led households, unemployment rate, and educational level. Table 7.3 also shows how a wide range of health indicators are related to income quintile. These indicators include age-standardized death rates, life expectancy, and death rates from specific diseases. For virtually every indicator, health is worse among the lowest-quintile population. Not surprisingly, the study also found that hospital use indicators (numbers of people hospitalized, number of discharges, and hospital days) was strongly related to income quintile with the rates highest for the lowest income areas. On average, the number of people hospitalized per 1000 residents was 102 in the poorest quintile, compared to 65 in the richest quintile. Similarly, the average number of days spent in hospital for the poorest quintile per 1000 residents was 937 days for the poorest quintile and 500 for the richest. But an important question is whether this clearly higher health need among lower-income people is translated into greater use of primary care and specialist services. If health care is provided on the basis of need, it would be expected that greater contact would be seen for lower-income people. As shown in Table 7.3, lower-income residents were more likely to see physicians, including general practitioners. But they were not more likely to see or be referred to specialists than those living in the wealthiest quintile of neighbourhoods. These findings concerning seeing specialists have been replicated by others. Dunlop and colleagues looked at national data from the National Population Health survey (Dunlop, Coyte, and McIsaac, 2000). They found that need of health care—itself related to income—was related to greater use of physician services. These services included both primary care and specialist care. However, when analyses looked specifically at income, it was found that while those in the lowest income quintile were more likely to access general practitioners, they were less likely than wealthier Canadians to have visited a specialist. These and other findings point to clear problems with universal access to specialist care among lower-income Canadians. The reasons for these findings have not been identified.

Finally, an extensive international study examined a very wide range of general and cost related access and medical bill problems among Canadians classified as below-average, average, and above-average in income (Schoen and Doty, 2004). The findings were that 20% of Canadians with below-average income found it difficult to see a specialist as needed, while only 14% of Canadians with above-average income had this problem. Canadians with below-average income were also more likely to have to wait more than five days or more to see a doctor (27% of these Canadians) than above-average income Canadians (20% of these Canadians). There was a variety of other physician-related issues identified by the study. Especially important were differences for cost-related access problems between above-average and below-average income Canadians.

In analyses that controlled for a wide range of factors such as age, education, minority status and residential location, below-average-income Canadians were—as compared to above-average-income Canadians—50% less likely to see a specialist when needed, 50% more likely to find it difficult to get care on weekends or evenings, and 40% more likely to wait five days or more for an appointment with a physician. There were no reliable differences between average-income Canadians and above-average income Canadians on these measures.

Additionally, below-average-income Canadians were four times more likely to report a dental problem but not see a dentist due to cost, and over four times more likely to have problems paying medical bills than above-average Canadians. On more specific measures of patient-doctor interaction, such as being treated with respect and dignity, having health concerns taken seriously, having enough time with the physician, and receiving good information, there were no differences among Canadians with higher-than-average income, average income, and below-average income.

Studies that have looked at dental care find a strong relationship between income and use of dental services. Income is related to seeing a dentist. The lower one’s income, the less likely they will have seen a dentist (Millar and Locker, 1999). This relationship holds for both those insured and not insured (see Figure 7.2), though Millar and Locker found that just about all low-income Canadians were not insured. They also found that the lowest-income quartile group of Canadians was more likely to have fillings and extractions than wealthier groups, but were less likely to come in for cleaning and insured check-ups.

Little detail is known about the actual lived experiences of people living in poverty withthe health care system. As part of a larger ethnographic study of women living in poverty, Reid (2004) found about half of women reported interactions to be generally negative. Reid identified two key issues. The first was that these women did not have resources to access the “extras” that keep one well. Two such examples are:

However, the primary concern of the women was not being able to afford aspects of health care that were not covered by the system. The reports of unsatisfactory interaction with health care providers are not consistent with the international study reported earlier (Schoen and Doty, 2004), but it should be noted that the Commonwealth study did not specifically identify the responses of people living in poverty.

Conclusions

Many people living in poverty are forced to interact with the social assistance system. The benefits they receive from this system are not at a level that allows for experiences consistent with what is expected to keep them living well and healthy within a developed nation like Canada. In addition, the social assistance system is frequently organized in such a way as to make receipt of assistance at best difficult, and at worse, degrading and humiliating. Additionally, governments have put forward the idea that people receiving social assistance are somehow undeserving of these benefits and of respect from others.

In contrast, interactions with the health care system seem to be relatively free of such problems. People living in poverty make greater use of the hospital system and are as likely to have access to primary care—with some exceptions—as people who are not living in poverty. They are, however, less likely to be referred to specialist care. The reasons for this have not been sufficiently investigated. In general, findings presented in this chapter indicated that social assistance is a process characterized by stigma, personal humiliation, and attitudes unworthy of a modern developed nation. In contrast, the organization and provision of services in the health care system are generally free of these issues. There are serious concerns, however, related to the ability of people living in poverty to access medicines, and additional required services. These problems appear to be especially relevant to issues of dental care.

We wish to thank Prof. Raphael for giving us permission to reproduce parts of his book on this site.

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