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2 Mechanisms and Methods: Looking at the Impact of Health Insurance on Health
Pages 25-45

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From page 25...
... The second section discusses issues related to the measurement of health insurance effects and considerations of research design that affect the inferences that can be drawn. It explores analytic strategies to distinguish the effects of health insurance status from those of personal attributes that are correlated with health insurance, including health status, race and ethnicity, and socioeconomic status, which may confound1 the results of studies that relate health insurance to health outcomes.
From page 26...
... Populationbased surveys conducted over the past three decades have evaluated access to primary care in relation to health insurance status with measures such as any physician visit within a year, the number of physician visits per year, having a regular source of care, and the ability to obtain care when needed (Freeman and Corey, 1993; Hafner-Eaton, 1993; Newacheck et al., 1998; Nelson et al., 1999; Zuvekas and Weinick, 1999; Haley and Zuckerman, 2000; Kasper et al., 2000; Shi, 2000; Weinick et al., 2000; Hoffman et al., 2001)
From page 27...
... Getting Care When Needed The ability to see a physician or other health care provider when one believes medical attention is needed is a fundamental and intuitive measure of access to health care. Most Americans mistakenly believe that people without health insurance have this level of access (IOM, 2001a)
From page 28...
... Having a Regular Source of Care In addition to supplying the financial resources that enable one to obtain health care when needed, insurance coverage also improves receipt of appropriate care by facilitating the use of a regular source of care or primary care provider.6 5Previously reported in IOM (2001a)
From page 29...
... . Even those uninsured adults who have chronic conditions are substantially more likely to lack a regular source of care than are chronically ill adults with health insurance.
From page 30...
... . In another study that compared transitions among health care plans to the complete loss of coverage, researchers found evidence of a temporary weakening of access to care among those who changed plans and a more pronounced loss of access among those who lost health insurance (Burstin et al., 1998)
From page 31...
... Such adjustment strengthens the analytic design of observational studies and increases the likelihood that the observed associations between health insurance and health outcomes represent a causal relationship. However, additional, less readily measured personal characteristics covary with health insurance status and may also affect health outcomes.
From page 32...
... Another potential source of bias in observational studies is the nonrandom distribution or selection of study participants among health insurance status categories. Health status is itself a determinant of health insurance coverage.
From page 33...
... Because most of those offered employment-based coverage do accept it and relatively few purchase individual coverage, this source of selection bias is not likely to substantially affect the overall comparisons between insured and uninsured adults. Major Covariates Personal characteristics that vary with health insurance status may confound analyses of the effects of health insurance on health-related outcomes because they are independently associated with these outcomes.
From page 34...
... . Ethnic differences in insurance status partially reflect differences in the rates of employment-sponsored insurance coverage.
From page 35...
... First, national studies that examine the health care and outcomes of uninsured adults mask a wide range of health care financing contexts within which care is rendered. Second, any evaluation of the care of uninsured adults reflects the financing and resource environment that
From page 36...
... Among Hispanics in the United States a greater degree of acculturation (and thus higher income) appears to be associated with a decline in health status (Vega and Amaro, 1994)
From page 37...
... Education and income are critical. Low educational attainment, poverty, and economic hardship have each been associated with higher rates of chronic illness, poor self-reported health status, disability, and lower life expectancy (Haan et al., 1987; Pincus et al., 1987; Marmot et al., 1991; Winkleby et al., 1992; Guralnik et al., 1993; Elo and Preston, 1996; Ostrove et al., 2000; van Rossum et al., 2000)
From page 38...
... Approximately 13,000 families and 36,000 persons are represented in five interviews conducted over 30 months. Data are collected on health status, health insurance coverage, health care use and expenditures, and sources of pay ment for health services.
From page 39...
... 3. Medical Provider Component -- A national sample of hospitals, physicians, and home health care providers.
From page 40...
... METHODS OF THE SYSTEMATIC LITERATURE REVIEW AND SYNTHESIS The Committee's literature review updates and broadens the scope of a number of extensive reviews of research measuring the effects of health insurance status on health-related outcomes. Notable prior contributions include Does Health Insurance Make a Difference, a background paper prepared by the Congressional
From page 41...
... • Screening and other secondary preventive services • Use of appropriate procedures (e.g., diagnostic and treatment services after acute myocardial infarction) • Adverse events due to medical mismanagement • Hospital admissions for preventable conditions The Committee excluded those studies that measured only basic access to care (e.g., number of physician visits per year, presence of a regular source of care, difficulty reported in obtaining care when needed)
From page 42...
... Studies that combine publicly insured and uninsured persons within a single category are included in the literature review because they may offer some insight into the factors that affect health-related outcomes, even though they do not yield results specific to uninsured adults and thus are of limited value in measuring the effects of uninsurance as such. Likewise, studies of health services utilization that report combined results for publicly and privately insured adults are included.
From page 43...
... This may be especially useful because health insurance coverage rules are often structured by service categories (e.g., preventive and screening services may be excluded or covered without any cost sharing to promote their use) but may also specify exclusions based on condition (e.g., mental illness)
From page 44...
... • Whether the health insurance status categories are well defined and con sistently reported. For example, is health insurance status directly measured?


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