Care Without Coverage Too Little, Too Late (2002) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-16
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• Uninsured adults with HIV infection are less likely to receive highly effective medications that have been shown to improve survival and die sooner than those with coverage. • Adults with health insurance that covers any mental health treatment are more likely to receive mental health services and care consistent with clinical practice guidelines than are those without any health insurance or with insurance that does not cover mental health conditions.
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General Health Status • Relatively short (one- to four-year) longitudinal studies document relatively greater decreases in general health status measures for uninsured adults and for those who lost insurance coverage during the period studied than for those with continuous coverage.
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Contrary to popular belief, Americans who do not have health insurance are at risk for poorer health as a result of their lack of coverage. In its first report, Coverage Matters: Insurance and Health Care, the Committee presented several popular myths about the lack of health insurance that indicated considerable public misunderstanding about the importance of coverage, which has hampered efforts to advance solutions.
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When followed over longer periods of time, uninsured adults have been found to be at higher risk of premature death than are persons with private coverage (Lurie et al., 1984, 1986; Franks et al., 1993a; Sorlie et al., 1994; Baker et al., 2001)
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Studies that focus primarily on adults 65 years and older were excluded because virtually all in this age group have health insurance coverage through the federal Medicare program.1 This report uses specific definitions of insurance and of the terms of coverage. "Insured adults" means those with general medical and hospitalization insurance, while "uninsured adults" are persons without any health insurance.
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Three characteristics of individuals are closely related to health insurance status and, as a result, require analytic adjustment: health status, race and ethnicity, and socioeconomic status. The strongest observational studies use adjustments to separate the effects of these characteristics from those of health insurance coverage.
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It does, however, facilitate receipt of preventive services, having a regular source of care, and improved quality of care. EFFECTS OF HEALTH INSURANCE ON SPECIFIC HEALTH CONDITIONS In the following discussion of health services and conditions, the evidence reviewed by the Committee is presented as follows: • primary prevention and screening services; • cancer care and outcomes; • chronic disease care and outcomes (including diabetes, cardiovascular disease, end-stage renal disease, HIV infection, and mental illness)
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Even after adjustments for age, race, education, and regular source of care, uninsured adults are less likely to receive timely screening for breast, cervical, or colorectal cancer. Once discovered, their cancer is likely to be at a more advanced stage.
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. Chronic Disease Care and Outcomes Finding: Uninsured adults living with chronic diseases are less likely to receive appropriate care to manage their health conditions than are those who have health insurance.
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. Cardiovascular Disease Uninsured adults with hypertension or high cholesterol have diminished access to care, are less likely to be screened, are less likely to take prescription medication if diagnosed, and experience worse health.
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. Uninsured adults with severe mental illnesses also receive less appropriate care or medications and experience delays in receiving services until they gain public insurance coverage (Rabinowitz et al., 1998, 2001; McAlpine and Mechanic, 2000)
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Poorer health status for uninsured adults when they are hospitalized is compounded by their experiences as inpatients. Being uninsured is associated with the receipt of fewer needed services, worse quality care, and greater risk of dying in the hospital or shortly after discharge (Hadley et al., 1991; Burstin et al., 1992; Haas and Goldman, 1994; Blustein et al., 1995; Doyle, 2001)
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Health Status Finding: Relatively short (one- to four-year) longitudinal studies document decreases in general health status measures for uninsured adults and for those who lost insurance coverage compared to per sons with continuous coverage.
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The Committee bases the following summary conclusions on the substantial consistency of results among the methodologically strongest observational studies in its review and the coherence of these results with the behavioral research that informs the Committee's conceptual model of mechanisms by which health insurance affects health outcomes: • Having health insurance is associated with better health outcomes for adults and with their receipt of appropriate care across a range of preventive, chronic, and acute care services. Adults without health insurance coverage die sooner and experience greater declines in health status over time than do adults with continuous coverage.
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The key lies in the role health insurance can play in facilitating access to care and the timely and appropriate use of services. In addition, if uninsured adults were insured on a continuous basis, their health status would likely be better than it would be otherwise and their risk of dying prematurely would be reduced.
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