Association for Public Policy Analysis & Management

Context: Achieving equity is a key goals of health care systems worldwide. This research examines the characteristics of countries’ health care systems that best promote the equity.

Methods: Nine countries are included: Australia, Canada, France, Germany, the Netherlands, Sweden, Switzerland, the U.K., and the U.S. Using four international data sets, the study employs 14 variables representing both objective and subjective measures of equity of access and subjective measures of experiences with the medical care system in each country. All of the measures compare those with low vs. high socioeconomic status. The study further defines several health care system characteristics, including: whether coverage is universal; the role of voluntary health insurance (VHI); the comprehensiveness of the benefit package; and the role of patient cost sharing.

Findings: The countries found to have the fewest equity problems are those that: provide universal coverage; do not rely heavily on VHI; include dental care as part of the mandated benefit package; and have modest cost sharing requirements. The countries that performed best in equity (the Netherlands and the U.K.) had systems consistent with the above traits. The countries that performed worst (Australia, Canada, France, Switzerland, and the U.S.) failed to meet one or more of these traits.

Conclusions: The most equitable systems are those that: cover everyone, all important services, have modest cost-sharing requirements, and do not rely on citizens owning supplemental insurance policies. Importantly, the type of system used in achieving universal coverage does not seem to be related to equity outcomes.