Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Purpose: Horizontal and vertical equity in healthcare utilization are necessary conditions for an optimal allocation of resources and consequently on welfare maximization. We employ alternative econometric count and discrete choice models to evaluate equity concerns in routine and preventive healthcare utilization.

Method: MEPS's Household Component (2004), a nationally representative survey of the U.S. civilian noninstitutionalized population, was used to evaluate the study objective. Analysis accounted for the complex survey design's primary sampling units, strata and sampling weights. Equity was defined on the principle of equal treatment for equal need. The need variables controlled in the model were perceived health status, presence of illness, comorbidities, activities and instrumental activities of daily living limitations. The non-need variables assessed for presence of horizontal equity were age, gender, race, ethnicity, income and education while controlling for variations in utilization caused by geographical and metropolitan area location and employment status. Presence of horizontal inequity was assessed by differences in utilization by non-need variables. Coefficients of need variables were also studied to confirm presence of vertical equity, which was defined as different levels of need variables consuming appropriate different levels of healthcare. Equity in routine healthcare utilization namely, emergency room visit (ER), inpatient hospitalization days (IPh), ambulatory hospital stays (AmbH), number of hospital discharges (nDIS), office-based provider visits (ObP), office-based physician visits (OMD), and prescription drug utilization (RxTot) were quantified. Binary measures of dental check-up, cholesterol check-up, blood pressure check-up, and flu shots assessed preventive healthcare utilization. Count utilization data were analyzed by poisson, negative binomial, zero-inflated poisson and zero-inflated negative binomial models while binary choice of preventive care was assessed by logistic and skewed logistic models. Data were analyzed using Stata 10.0 and SAS 9.1 softwares.

Results: The mean age of the sample was 36.5 (±22.3) years, with a majority of females (51%), white (80.5%), married (53%) and high school diploma holders (34.8%). Amongst the non-need variables, statistically significant horizontal inequity was observed in age for utilization in ER, IPh, nDIS, ObP, OMD, and RxTot. Inequity in gender was observed in utilization of IPh, nDIS, ObP, OMD, RxTot and AmbH. Inequity by race and ethnicity was observed in utilization of all routine care variables. Income related inequity was observed in ER, IPh, ObP, OMD, RxTot, and AmbH. The necessary condition for vertical equity was satisfied in most models of routine healthcare utilization. Evidence of horizontal inequity was observed in all four preventive care variables by age, gender, ethnicity, income and education. Horizontal inequity by race was observed in cholesterol check-up, blood pressure check-up and receipt of flu shots. Higher level of need was not associated with higher level of utilization in preventive care utilization models and thus the necessary condition for vertical equity was not satisfied.

Conclusion: Horizontal inequity in age, gender, race, ethnicity, income and education and the lack of vertical equity in preventive care may be an indication of sub-optimal allocation of resources in the US population.