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Copayments and the evidence-base paradox

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To the Editor: The recent perspective by Keane on the effects of copayments on low-income populations1 overlooked the results of the 1968 decision in the Canadian province of Saskatchewan to impose a fee of $1.50 (all amounts are in Canadian dollars) for office visits and $2.00 for home, emergency department or hospital outpatient visits.

At the time the fees were introduced, the definition of low income was $1550 for single-person families to $4800 for families of five or more. The result of the fee was a statistically significant 14% decrease in the use of general practitioner services and a non-statistically significant decrease of 5% in specialist services by the poor.2 The health outcomes effect of this decrease in the use of services was not examined.

The Saskatchewan natural experiment should serve as a reminder that even small amounts of money can affect the volume of services that the poor receive.