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'The assumption that access to prompt, affordable health care improves the health of socially disadvantaged groups is a core belief for those who support systems of universal health care," David Alter, a senior scientist at the Institute for Clinical Evaluative Sciences, writes in a fascinating new article published in Thursday's edition of the journal Health Affairs.

"These advocates further assume that if preventive and therapeutic care is made universally available, people who need the care will use it, and the care will mitigate the disadvantages that result from low socioeconomic status."

However, Dr. Alter notes, there is very little research that tests those assumptions. So he and a team at ICES set out to do so.

Their study followed 14,800 Ontarians for more than a decade. At the outset, none of them had cardiovascular disease. The researchers examined patients' health service use, disease progression and survival experiences. (They focused on cardio-

vascular disease because it is so common: 90 per cent of Canadians have at least one risk factor for heart disease and it is a leading cause of death.) Dr. Alter and his team found - to no one's surprise - that people who were socially disadvantaged (meaning they have a low income and/or low levels of education) suffered a lot more cardiovascular disease. They also had higher mortality rates than their more educated, more affluent counterparts.

That socioeconomic status and disease patterns are strongly associated in a gradient is well-established.

But does medicare - universal access to health services - alter that association?

The conclusion from the new research: not really.

Dr. Alter - who is also a scientist at the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital in Toronto - found that the poor use significantly more health services than the wealthy, something they obviously could not do if they had to pay.

But that increased use doesn't translate into better outcomes.

The poor visit physicians and hospitals more often not because it's free but because they're sicker. They have more diabetes, more heart attacks, more strokes. And much higher death rates.

What the rich and poor have in common though is that they tend to access health care services reactively - meaning they only go to the doctor when they have symptoms or disease-related complications.

In other words, there is very little preventive health care going on even though medicare should lend itself to this approach.

This research tells of opportunity lost but it does not, in any way, argue against universal health care.

In fact, it points to some real benefits of medicare: Patients, regardless of socioeconomic status, had pretty equal access to general practitioners and specialists alike and they received similar hospital care.

But Dr. Alter, in the conclusion of his paper, has an important message for countries that are looking to bolster their publicly funded health insurance program, such as the United States and South Africa: "They should not rely on this approach alone

to eliminate the inequities that disadvantaged sectors of their populations continue to experience today."

It is a message that needs to find an echo here in Canada as well.

Medicine matters but the universal access to sickness care is not nearly enough to ensure that Canadians get and stay healthy. If anything we should be spending less on our sickness care and more on giving Canadians the tools to get healthy in the first place.

There are, in the new paper, some telling data: A high-income patient (one earning $50,000 or more annually) had only 35 per cent as much risk of dying during the study period as a low-income patient (one earning less than $30,000). Similarly, a highly educated patient (a university degree) had only 26 per cent of the mortality risk of a less educated one (not having finished high school). Those disparities are staggering.

Stated bluntly, the best health promotion tool we have is a good education system and the best medicine we have is money.

Medicare is an important social program but it cannot ensure a healthy population, particularly not in a vacuum.

In Canada today, more than 40 per cent of government budgets are allocated to health care; education (primary, secondary and postsecondary) gets about 25 per cent; and social welfare programs hover at about 15 per cent.

Despite the illusion we have a generous social safety net, our social welfare spending is about half as much as that of many European countries. They spend less on health and have better health outcomes.

Our efforts to prevent and treat illness are doomed to failure unless we are going to make an equal or greater effort to tackle poverty, poor housing and inequality, and bolster education and create healthier environments - the socioeconomic determinants that renowned social scientist Sir Michael Marmot calls the "causes of the causes of poor health."

We have reason to be proud of medicare but our investment in that program - financial and emotional - too often blinds us to the fact that the greatest beneficiaries are the comfortable, principally middle-class citizens and corporations. Those with good incomes and a decent education have all the benefits this affords and, in addition, affordable health premiums (in the form of taxes) thanks to the pooling of risk that is the foundation of medicare. A win-win.

For the socially disadvantaged, our current approach to medicine and health does provide good access to sickness care but not good health. It's much like closing the barn door after the horse has escaped.

In this country, we have for far too long pretended that universal health insurance will produce a universally healthy population.

If only it were that simple.