Unmet health needs greatest among people uninsured more than 1 year
CHICAGO - American adults without health insurance are less likely than insured adults to receive preventive care or routine checkups, and more likely to report they could not see a physician because of cost, according to an article in the October 25 issue of The Journal of the American Medical Association, a theme issue on access to care.
John Z. Ayanian, M.D., M.P.P., of Brigham and Women's Hospital and the Harvard Medical School, Boston, and colleagues, compared survey data to estimate the unmet health needs of insured and uninsured U.S. adults. The study population was representative of more than 163 million U.S. adults aged 18 to 64 years residing in households during 1998 and approximately 161 million comparable adults in 1997. The study included 105,764 people aged 18 to 64 surveyed in 1997, and 117,364 surveyed in 1998, who were classified as long-term uninsured (without health insurance for a year or longer), short-term uninsured (without insurance for less than a year), or insured. Data came from the Behavioral Risk Factor Surveillance System (BRFSS), a federally funded survey designed by the Centers for Disease Control and Prevention (CDC) in collaboration with state health departments. Since 1994, all 50 states and the District of Columbia have administered the BRFSS survey and submitted data to the CDC.
According to background information cited in the study, approximately 33 million U.S. adults aged 18 to 64 were without health insurance in 1998. Prior studies have documented that lacking health insurance is associated with important clinical consequences. Uninsured adults are more likely than insured adults to report poor health status, delay seeking medical care, and forgo necessary care for potentially serious symptoms. Uninsured adults receive fewer screening services for cancer and cardiovascular risk factors, present with later-stage diagnoses of cancer, and experience more avoidable hospitalizations. They also face an increased risk of death, particularly when hospitalized or diagnosed as having breast cancer.
Among Americans surveyed for the BRFSS in 1998, 9.7 percent were long-term uninsured, 4.3 percent were short-term uninsured, and 86 percent were insured. Proportions of uninsured individuals were higher among younger adults, men, blacks, Hispanics, residents of the South and West, those with less education and lower incomes, and those who were self-employed, unemployed, or not in the labor force. Adults whose self-reported health status was good, fair, or poor were 2 to 3 times more likely to have been uninsured for 1 year or longer than those who reported excellent or very good health.
"Long-term and short-term uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost," the authors write. 26.8 percent of long-term uninsured and 21.7 percent of short-term uninsured adults said cost kept them from seeing a physician, compared to 8.2 percent of insured adults. This was especially true among those in poor or fair health.
"Long-term uninsured adults in general were much more likely than short-term uninsured and insured adults not to have had a routine checkup in the last 2 years," the authors write. 42.8 percent of long-term uninsured adults said they had not had a routine checkup over the previous 2 years, compared with 22.3 percent of short-term uninsured and 17.8 percent of insured adults.
Long-term uninsured adults also received fewer preventive services, including cancer screening, cardiovascular risk reduction, and diabetes management. "Long-term uninsured adults were significantly more likely than insured adults to have unmet needs for each of these services, except for glycosylated hemoglobin measurements and pneumococcal vaccinations among adults with diabetes and HIV screening among those with self-perceived risk. For clinical services such as breast cancer or hypertension screening, long-term uninsured adults were 3 to 4 times more likely not to have received these services," the authors write.
"Alarmingly high proportions of long-term uninsured adults in poor or fair health reported forgoing needed care, including about two thirds of those in poor health and half of those in fair health," the authors assert. "These findings challenge the views of a growing proportion of Americans - from 43 percent in 1993 to 57 percent in 1999 -- who believe that uninsured people are able to get the care they need from physicians and hospitals."
The authors believe that providing insurance to improve access to care for long-term uninsured adults, particularly those with major health risks, could have substantial clinical benefits.
"The federal and state governments have begun to extend affordable health insurance to uninsured children in the United States by expanding Medicaid and launching the Children's Health Insurance Program. In contrast, the unmet health needs of 33 million uninsured adults continue to fester in the health care system without a cohesive political response by the federal government or most states. Concerted and collaborative action by policymakers and health care professionals will be required to address these persistent needs," they conclude.
(JAMA. 2000; 284:2061-2069)
Editor's Note: This study was funded by the American College of Physicians-American Society of Internal Medicine.
Media Advisory: To contact John Z. Ayanian, M.D., M.P.P., call John Lacey at 617-432-0441.
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