Many psychiatrists, including myself, advocate for universal access to health care for all Americans. I have always favored a single-payer approach like the Canadian system, in which everyone is covered for needed treatment, including psychiatric treatment. A key barrier to gaining access to care is economic discrimination, and the push toward parity in this country is a major effort to overcome the historic difficulty of our patients' and families' receiving effective care. We often point to Canada as the model of nondiscriminatory coverage and equal access for all.

But what if a universal, single-payer approach provides for better access for people with higher incomes and lower morbidity than for those in lower socioeconomic groups with serious mental illness? What if parity does not lead to equity? A study by Steele and colleagues in this issue of Psychiatric Services demonstrates that in the Toronto area, beneficiaries in higher socioeconomic neighborhoods were nearly twice as likely as those in lower socioeconomic neighborhoods to use psychiatric care. More visits, more claims, and lower morbidity all characterized the claimants in the higher socioeconomic neighborhoods.

This well-designed study demonstrates to those of us who advocate for a Canadian style of universal insurance that equal access to care with no financial barriers is not equal for all people. The disconnect between service need and service use by socioeconomic class reflects issues such as language and cultural barriers, stigma, and the fact that psychiatrists prefer a caseload that consists of mildly depressed or anxious patients who come regularly for visits rather than patients with chronic psychosis or addiction who may miss appointments and have emergency needs. Regardless of the reasons for this disparity in access to care, one question must be, Why should everyone pay taxes if people from higher socioeconomic strata use services disproportionately? Should these less ill, wealthier patients pay for more of these services themselves?

The single-payer Canadian system has no copayments or deductibles and no managed care. Should these economic incentives be introduced for persons of a higher socioeconomic status, and if so, how? Will these incentives undermine the basic goal of universal coverage and access? In this country, we use copayments and deductibles to deal with issues of use and potential overuse of services. In addition, we use managed care reviewing the "medical necessity" of treatment. Would managed care effectively address the equity issue in Canada? In a universal health care access plan in the United States, could managed care help avoid the distributive equity problem experienced in Canada? We will not overcome the equity problem of equal access to care by just providing economic access. We need to do more.