Single-payer healthcare solves a lot of problems—dizzying insurance premiums, preexisting condition jeopardy—just not all of them.
Prejudice, like diabetes, is a condition for which no drug yet exists, and as a new bit of research in the Canadian Medical Association Journal demonstrates, even physicians working in a universal care system aren’t immune to its effects.
Stephen Hwang, an internist at the University of Toronto, wanted to know just how endemic socioeconomic discrimination was in local clinics. “I provide care for a number of people who are homeless and marginalized in society,” he says, “and they not infrequently mention to me that they feel that, in the past, they’ve been treated differently by certain health care providers. They feel that it was simply because they were poor or homeless.”
Hwang, along with colleagues Michelle Olah and Gregory Gaisano, decided to explore that complaint by calling the offices of 375 primary care physicians in Toronto, posing as a first-time patient. Half the time, the “patient” explained that he was an executive at a major bank, just transferred to town, looking for a new family doctor; in other cases, the “patient” was a welfare recipient whose caseworker had instructed him to start receiving annual check-ups.
The authors discovered that a rich patient’s odds of getting an appointment were nearly one in four, while a poor patient’s were one in seven. While “physician reimbursement is unaffected by patients’ socioeconomic status” in a universal system, they write, affluent Canadians “received preferential access to primary care” over their lower-class countrymen.
“What we found was about what we suspected was going on,” says Hwang, who went to medical school at Johns Hopkins and studied public health at Harvard before moving to Toronto. “Having practiced in both the U.S. and Canada, I think that while the Canadian system of universal health insurance provides much more equitable access for people of all income levels and social background, what it doesn’t eliminate is a universal predisposition to treat people differently because of their status in society.”
At the same time, the researchers found that a “patient” complaining of chronic conditions—back pain or diabetes—was far more likely to receive an appointment than one simply looking for an their annual wellness check. And that’s a good thing, says Hwang. Doctors, many of them already heavily oversubscribed, seem to be prioritizing the sickest Canadians. (Although it’s also possible that they stood to bill more services to a patient with a chronic illness.)
Hwang is quick to note that the study is hardly a condemnation of single-payer care. “I think that people are by and large better off in the Canadian health care system than in the United States, both in terms of equity and outcomes overall,” he says. Still, the findings are a useful reminder that physicians are only human; like all of us, they suffer from ugly, if unconscious, prejudices and predilections. And for that malady, there’s no easy cure.