Comparison of health care utilization: United States versus Canada.

Differences in health care systems in the United States and Canada have garnered immense interest in recent years in view of rising health care expenditures and recent debates about approaches to health insurance coverage and access to health care. In Canada, health insurance covers expenses for physician and hospital services, with costs primarily financed by the federal, provincial, and territorial governments. In contrast, health coverage in the United States is provided through a mixture of public and private insurance, leaving a large percentage of the population underinsured and uninsured—with estimates showing 29 million underinsured adults in 2010 (Schoen et al. 2011) and 41.3 million uninsured in 2009 (Chu and Rhoades 2011). The different approaches to health care financing and coverage in Canada and the United States present an opportunity to examine differences within and across subpopulations in the use of health care services. The objective of our article is to examine differences in health care use between the two countries' total populations1 and residents who are considered “vulnerable” regarding their access to and use of health care. Equitable utilization of health care can be assessed by comparing segments of the population who are likely to have barriers in accessing health care. To the extent that health coverage reduces the cost of health care services, health care may be more affordable for low-income groups living in countries with universal coverage. Immigrants or the foreign-born are another segment of the population often deemed “vulnerable.” Conditional on income and educational attainment, immigrants may have language barriers, lack knowledge about the mechanisms of obtaining coverage, be employed in firms that do not offer coverage, and may be time constrained in accessing care. The presence of universal coverage may reduce some of these barriers for the foreign-born population. Finally, access to care among the less educated population can be quite challenging in countries without universal coverage, for reasons similar to those of immigrants and low-income populations. Comparing the three subpopulations across a wide spectrum of health care measures provides us with valuable information about the role of the health systems in reducing differences in health care access and use in the two countries. Our study contributes to the previous literature on several fronts. First, we focus on a wide range of health services, many of which have not been compared between the two countries in the previous literature. In particular, we examine differences in having a usual source of care, visits to medical providers, nurses, chiropractors, dentists, and specialists, as well as overnight hospital stays, the use of Pap smear tests, and the use of mammograms. Second, our study uses much larger data sets than what were used in the previous literature, enabling us to improve the precision of estimates. Third, in addition to analyzing utilization behavior of the total population in the two countries, we focus on vulnerable subpopulations that were not comprehensively examined in a previous literature. We use two nationally representative surveys—the Medical Expenditure Panel Survey (MEPS) for the United States and the Canadian Community Health Survey (CCHS) for Canada to examine differences, overall and across subpopulations, in the use of health care. Because the two surveys are independent, the wording and the ordering of questions asked are not identical and may contribute to the differences in results. For key variables of interest, we compared estimates of utilization rates obtained from the MEPS and the CCHS with the Joint Canada/United States Survey of Health (JCUSH), which interviewed individuals consistently in the two countries. We find that for those variables that were available in the three surveys, the point estimates and the differences in utilization obtained from the MEPS and the CCHS were very similar to those from the JCUSH. We opted to use the MEPS and the CCHS over the JCUSH because the MEPS and the CCHS provide more information on health services use and have larger sample sizes than the JCUSH. Moreover, the JCUSH collects information using random telephone dialing, which implies that individuals without phone lines may not have been interviewed. Although the percentage of persons without telephones are relatively small (4.4 in the United States and 1.8 in Canada), persons without telephones are likely to be poor, less educated, and foreign-born—a key focus of our analysis.