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3 Effects of Health Insurance on Health
Pages 46-89

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From page 46...
... • The most compelling evidence for the difference that health insurance can make in health outcomes is in chronic disease care and in prevention and screening. Studies of acutely ill or injured patients and of the general mortality experience of insured and uninsured populations also provide evidence for concluding that health outcomes are better for privately insured than for uninsured adults.
From page 47...
... , use of medical care and health outcomes for specific conditions and types of services, and with overall health status and mortality. There is a consistent, positive relationship between health insurance coverage and health-related outcomes across a body of studies that use a variety of data sources and different analytic approaches.
From page 48...
... For prevention and screening services, health insurance facilitates both the receipt of services and a continuing care relationship or regular source of care, which also increases the likelihood of receiving appropriate care. Insurance benefits are less likely to include preventive and screening services (Box 3.2)
From page 49...
... . Yet even if health insurance benefit packages do not cover preventive or screening services, those with health insurance are more likely to receive these recommended services because they are more likely to have a regular source of care, and having a regular source of care is independently associated with receiving recommended services (Bush and Langer, 1998; Gordon et al., 1998; Mandelblatt et al., 1999; Zambrana et al., 1999; Cummings et al., 2000; Hsia et al., 2000; Breen et al., 2001)
From page 50...
... The odds ratios (ORs) for receiving a screening service if uninsured compared with having private health insurance ranged from 0.27 for mammography to 0.43 for Pap test.3 The 1998 NHIS found that, although rates of screening at appropriate intervals had increased generally over the preceding decade, they remained substantially lower for uninsured adults than for those with any kind of health insurance (Breen et al., 2001)
From page 51...
... . Studies of the use of preventive services by particular ethnic groups, such as Hispanics and African Americans, find that health insurance is associated with increased receipt of preventive services and increased likelihood of having a regular source of care, which improves one's chances of receiving appropriate preventive services (Solis et al., 1990; Mandelblatt et al., 1999; Zambrana et al., 1999; Wagner and Guendelman, 2000; Breen et al., 2001; O'Malley et al., 2001)
From page 52...
... Multivariable data analysis is used to determine the independent effects of health insurance, by controlling for demographic, SES, and clinical differences among study subjects. In addition to receiving fewer cancer screening services, uninsured adults are at greater risk of late-stage, often fatal cancer.
From page 53...
... . Both because of an assumption of similarity in SES between uninsured and Medicaid patients and because of small numbers of observations in the separate categories, some studies report combined results for Medicaid and uninsured patients and compare these findings with those for privately insured patients (e.g., Lee-Feldstein et al., 2000)
From page 54...
... , taken together, were twice as likely as privately insured women with indemnity coverage to be diagnosed at a late stage of disease. Over a four- to ten-year follow-up, uninsured and publicly insured women had higher risks of death from both breast cancer (42 percent higher)
From page 55...
... In a multivariable analysis adjusting for sociodemographic characteristics, smoking status, and comorbidities, uninsured patients were more likely to be diagnosed with late-stage colorectal cancer than were patients with private indemnity coverage (OR = 1.67)
From page 56...
... that adjusted for sociodemographic factors and comorbidities but not for smoking estimated the adjusted mortality risk for uninsured patients with colorectal cancer to be 64 percent greater over a three- to four-year follow-up period than that for patients covered by private indemnity plans (Roetzheim et al., 2000b) .5 Even after adjusting for stage of disease at diagnosis, the risk of death for uninsured patients was 50 percent higher than that for the privately insured, and after further adjustment for treatment modality, the risk for uninsured patients was 40 percent higher (Roetzheim et al., 2000b)
From page 57...
... For the five disease conditions that the Committee examined (diabetes, cardiovascular disease, end stage renal disease, HIV infection, and mental illness) , uninsured patients have worse clinical outcomes than insured patients.
From page 58...
... . For uninsured patients without a regular source of care or those who identify an emergency department as their usual source, obtaining care that is consistent with recognized standards for effective disease management is a daunting challenge.
From page 59...
... Uninsured adults are less likely to receive routine screening services for cardiovascular disease. A nationwide household survey in 1997 found that adults who had been without health insurance for one year or longer were less likely than insured adults to have received recommended hypertension screening within the previous two years (80 percent compared with 94 percent)
From page 60...
... The 1987 National Medical Expenditures Survey afforded an in-depth examination of the use of antihypertensive medications by health insurance status. Uninsured persons younger than 65 who had hypertension were less likely than either those with private insurance or Medicaid to have any antihypertensive medication therapy (ORs = 0.62 and 0.44, respectively)
From page 61...
... of patients presenting to two New York hospital emergency departments between 1989 and 1991 found that uninsured patients were more likely to have severe, uncontrolled hypertension than were sociodemographically similar patients with any health insurance (OR = 2.2) , while patients without a regular source of care had an even greater risk of severe and uncontrolled disease (OR = 4.4)
From page 62...
... . End-Stage Renal Disease Finding: Uninsured patients with end-stage renal disease begin di alysis at a later stage of disease than do insured patients and have poorer clinical measures of their condition at the time they begin dialysis.
From page 63...
... therapy than patients with any kind of insurance pre-ESRD. Uninsured patients also had an increased likelihood of hypoalbuminemia than those who had previously been privately insured (OR =
From page 64...
... Uninsured patients were also less likely than privately insured patients to have received EPO prior to dialysis (OR = 0.49) (Obrador et al., 1999)
From page 65...
... .11 These surveys allow assessment of the relationship between health insurance and access to care, use of services, receipt and timeliness of recommended therapies, and mortality as related to health insurance status. The research based on one of these surveys, the HIV Cost and Services Utilization Study (HCSUS)
From page 66...
... , suggesting poorer access to other kinds of outpatient care. Studies based on earlier data report that uninsured patients had lower use of emergency rooms and hospitalization than either publicly or privately insured patients (Mor et al., 1992; Fleishman and Mor, 1993; Niemcryk et al., 1998; Joyce et al., 1999)
From page 67...
... . Uninsured patients were significantly less likely than privately insured patients with indemnity coverage (OR = 0.71)
From page 68...
... . Despite the differential treatment of mental health services in both public and private insurance plans, the studies reviewed by the Committee document a positive association between health insurance coverage and more appropriate care for mental illnesses (Box 3.9)
From page 69...
... . As discussed below, those with severe mental illness also experience transitions in insurance coverage, frequently ending up with public program coverage (Rabinowitz et al., 2001)
From page 70...
... Severe Mental Illness Uninsured adults with severe mental illnesses are less likely to receive appropriate care than are those with coverage and may experience delays in receiving services until they gain public insurance. In a study using the same sample and survey as that used by Young and colleagues, McAlpine and Mechanic (2001)
From page 71...
... was significantly higher for the publicly insured group compared to both those with private insurance and those with no insurance during the first 6 months after initial hospitalization and over the entire 24-month period. Uninsured patients with SMI were much less likely to receive outpatient care after hospitalization than patients with Medicaid or Medicare (OR = 0.24)
From page 72...
... , lengths of stay were not significantly different for uninsured and privately insured patients, although uninsured patients tended to have shorter stays. This underscores the possibility that when uninsured patients are found to receive 12Older studies that examine hospital-based care and outcomes according to insurance status across a range of diagnoses are summarized in Appendix B
From page 73...
... One study of more than 30,000 hospital medical records in 51 hospitals in New York State for 1984 found that the proportion of adverse medical events due to negligence was substantially greater among patients without health insurance than among privately insured patients (OR = 2.35) , while the experience of Medicaid patients did not differ significantly from that of the privately insured population (Burstin et al., 1992)
From page 74...
... Adjusting the data for injury severity and comorbidities as well as for age, sex, and race, the authors found that uninsured trauma patients received less care and had higher in-hospital mortality than did patients with private insurance or Medicaid. Uninsured patients were just as likely to receive care in an intensive care unit (ICU)
From page 75...
... examined hospital discharge records of more than 91,000 adults diagnosed with acute appendicitis in California hospitals between 1984 and 1989. They found that the risk of a ruptured appendix was 50 percent higher for both uninsured and Medicaid patients, than for privately insured patients in prepaid plans, in an analysis that controlled for age, sex, race, psychiatric diagnoses, diabetes, and hospital characteristics.
From page 76...
... For those with less severe head injuries (lacerations, contusion, or concussion) , uninsured patients were substantially less likely than privately insured patients to be admitted to the hospital (OR = 0.14 for laceration, 0.38 for contusion or concussion)
From page 77...
... . The first study, of about 5,000 patients admitted on an emergency basis for AMI in 1987, found that uninsured patients were more likely to die within 30
From page 78...
... Coronary Procedures The body of research on the use of specific procedures to diagnose and treat cardiovascular disease as a function of the insurance status of the patient consistently reports differences in utilization, with uninsured patients generally less likely to receive coronary angiography, CABG, or percutaneous transluminal coronary angioplasty (PTCA) than privately insured patients (Young and Cohen, 1991; Blustein et al., 1995; Kuykendall et al., 1995; Sada et al., 1998; Leape et al., 1999; Canto et al., 2000; Daumit et al., 2000)
From page 79...
... found that uninsured patients were less likely than privately insured patients to be admitted initially to a hospital that offered revascularization and much less likely to be transferred if admitted initially to one that did not (ORs = 0.71 and 0.42, respectively)
From page 80...
... longitudinal studies document relatively greater decreases in general health status mea sures for uninsured adults and for those who lost insurance coverage during the period studied than for those with continuous coverage.
From page 81...
... .16 Because insurance status was measured only at the initial interview and thus did not reflect the subjects' cumulative insurance experience over the 13–17 year follow-up period, the difference found in mortality between uninsured and privately insured persons most likely is an underestimate of differences in the mortality experience of those who are continuously uninsured and those who are continuously insured. A study by Sorlie and colleagues (1994)
From page 82...
... Like those with chronic health conditions, adults in late middle age are particularly susceptible to deteriorations of function and health status if they lack or lose health insurance coverage. Baker and colleagues (2001)
From page 83...
... , National Medical Expenditure Survey [NMES] , and Behavioral Risk Factor Surveillance System, provide snapshots of the subjective or self-reported health status of populations according to insurance status.
From page 84...
... health outcomes for the general population to cost sharing. Negative Results Some studies have reported worse health status for those with health insurance compared to uninsured adults.
From page 85...
... Changes in these measures between baseline and follow-up were also included as predictors of health status, functional status, and number of chronic conditions at follow-up in 1998. The authors concluded that privately insured and uninsured persons had similar health status at a three-year follow-up, adjusted for baseline health status, chronic conditions, and sociodemo-graphic characteristics, and that publicly insured persons had worse health status than privately insured and uninsured adults (Ross and Mirowsky, 2000)
From page 86...
... Being without health insurance for longer periods increases the risk of inadequate care for this condition and can lead to uncontrolled blood sugar levels, which, over time, put diabetics at risk for additional chronic disease and disability. • Uninsured patients with end-stage renal disease begin dialysis with more severe disease than do those who had insurance before beginning dialysis.
From page 87...
... The Committee has assessed the research regarding the effects of health insurance status across a range of health conditions and services affecting adults. In each domain examined -- • preventive care and screening services, • cancer care and outcomes, • chronic disease management and patient outcomes, • acute care services and outcomes for hospitalized adults, and • overall health status and mortality,
From page 88...
... Chapter 4 specifically addresses the question of the difference that providing health insurance to uninsured individuals and populations would make to their health and health care. The Committee assesses the potential impact of health insurance coverage on those uninsured adults who are most at risk for poor or adverse health-related outcomes, including the chronically ill, adults in late middle age, members of ethnic minorities, and adults in lower-income households.


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