Capsule Commentary on Okunrintemi et al., Association of Income Disparities with Patient Reported Healthcare Experience

Okunrintemi’s¹ analysis of 2010–2013 Medical Expenditure Panel Survey (MEPS) data on income-related disparities in experiences with the healthcare system is an important contribution to the literature. The finding of worse access to care, delays in care, and dissatisfaction with the care received by low-income individuals is certainly not surprising but should nonetheless be alarming given the current retreat on recent healthcare reforms designed to enhance equity in the delivery and receipt of care in the USA. The authors’ findings were fairly similar across racial and ethnic groups when adjusted for income (figure e1) but the income disparities in healthcare experience were accentuated by lack of health insurance (figure e2).

This analysis of recent nationally representative survey data confirms that there is substantial income-based disparity in patient healthcare experiences just as there are substantial disparities in healthcare outcomes in the USA.^{2, 3} Since healthcare in the USA is a moving, evolving target, this report is limited by the survey data being 6–8 years old—pre-dating implementation of the Affordable Care Act. It will be interesting to see whether more recent MEPS Survey panels demonstrate different healthcare experiences by income and insurance subgroup. Though the reported analyses are restricted to patients having a “regular healthcare provider” (which might tend to level the playing field across incomes), results were similar without this restriction (Table e3).

Though the authors appropriately state that a “multipronged strategy” is needed to address this income disparity, a logical first step in my opinion would be to remove the insurance barrier (though only one of many barriers that poverty presents) with a system of universal health coverage. Unfortunately, we have recently moved in the opposite direction and, as Okunrintemi¹ points out, recent CMS “pay for performance” incentives may further disadvantage healthcare providers and systems caring for poor under-served populations given their lower performance ratings. Accountable Care Organization incentive structures will likely have a similar adverse impact on lower socioeconomic status populations.⁴ We must avoid the vicious cycle of poverty-driven health outcome failures begetting fewer healthcare resources rather than the large investment actually needed to address existing inequities and the many barriers to better health.⁵