Healthcare for All Not Quite a Reality in Canada

By Uduak Thomas, M.A.

There’s an interesting study that was just published in the Canadian Medical Association Journal by a research team in Canada that brings some rather surprising inequalities in the nation’s healthcare system to light. By conducting telephone-based survey, the researchers discovered that some family physicians’ offices discriminate against people who would be considered of low socio-economic status.

The paper explains the research led by Dr. Stephen Hwang, a general internal medicine physician at Canada’s St. Michael hospital and a researcher in its Center for Research on Inner City Health. They called the offices of 568 family physicians and general practitioners in the Toronto area posing as either a bank employee or a welfare recipient and pretending they needed a primary care physician.

They found that the proportion of calls resulting in an appointment was significantly higher for people with high socio-economic status (22.6 per cent) than for people with low socio-economic status (14.3 per cent) of the 375 offices from which they obtained data. If an offer of a screening visit with the physician or a spot on a waiting list is also counted, the difference is 37 percent for people with high status with 24 percent for those with low status.

One of the more puzzling things about these results is that under Canada’s universal health insurance scheme, physicians are reimbursed equally for each patient so the reason isn’t a financial one. The paper doesn’t really provide an explanation but it does note that there is research that shows that physicians “perceive patients with low socioeconomic status more negatively in terms of their personalities, abilities, behavioural tendencies and role demands.” However they also note that this isn’t necessarily discrimination on the basis of socio-economics.

Obviously, we can’t over-generalize. This is one quite small study, focused on one arm of medicine in one part of Canada. Without additional studies, there is no way to know if it is representative of the larger state of things.  Also, there’s no clear link to the physicians that were surveyed. Hwang’s team reported that they spoke mostly to administrative assistants and secretaries whose behavior may not necessarily be sanctioned by their employers.

Still, discrimination no matter how miniscule it seems or whatever form it takes needs to be nipped in the bud. Studies like these are a good lesson for countries mulling over such universal systems so that they take preemptive steps to ensure that such behavior doesn’t have a chance to rear its head. It’s also a reminder to those that do to review their infrastructure and policies, checking for compliance.

In Canada, Hwang is calling for stricter enforcement of the medical college’s rules — which does have policies against cherry picking patients. He was also recently appointed St. Michael’s first endowed Chair in Homelessness, Housing and Health, which is believed to be the first hospital-based chair in homelessness in the world. In this role, he’ll support research and innovation in the provision of care to marginalized populations, both locally and nationally.

There is one silver lining. During the call, the researchers also reported that they either had or did not have some kind of chronic health issue, for example diabetes or low back pain. They found that persons that had chronic health issues were more likely to get appointments than those that did not; 23.5 percent compared to 12.8 percent. It’s not clear from the study whether socio-economic status was a factor in this particular decision, but at least it’s a positive sign.


Michelle E. Olah, Gregory Gaisano, Stephen W. Hwang. “The effect of socioeconomic status on access to primary care: an audit study.” Canadian Medical Association Journal doi:10.1503/cmaj.121383

Uduak Thomas, M.A., is a journalist and science writer specializing in medical research and healthcare. She is Social Media Editor for Cancer InCytes Magazine.

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