Myth challenged: uninsured adults not receiving needed care
Two-thirds of the nation's uninsured adults go without health insurance for longer than one year
BOSTON-October 24, 2000-National surveys reflect a growing perception that the United States' uninsured can obtain proper health care through various "safety net" facilities. Not true says a study led by Harvard Medical School researchers in this week's issue of the Journal of the American Medical Association, which revealed high proportions of long-term uninsured adults in poor or fair health who are not getting needed medical care.
"Many uninsured adults are going without proper medical attention," says the study's lead author, John Ayanian, MD, MPP, associate professor of medicine and of health care policy at Harvard Medical School and Brigham and Women's Hospital. "Thirty-two percent of women without health insurance for over a year report not getting a mammogram in the past two years. Twenty-six percent of the long-term uninsured with hypertension or diabetes say they haven't had a check-up with a doctor in two years. From a public health perspective, these numbers are very concerning."
According to the study, which examined 1997-98 survey data for over 220,000 adults aged 18 to 64 from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, 14 percent lacked health insurance, and nearly 10 percent had gone without health insurance for at least a year. These percentages are representative of the approximately 163 million U.S. adults living in households with telephones. Nearly two-fifths of the long-term uninsured adults (those without health insurance at least a year) and one third of the short-term uninsured, reported not being able to see a physician when needed in the past year due to cost. Cost barriers to seeing a physician among uninsured adults were greatest for women, blacks, the unemployed, and those with low incomes.
The numbers were worse for those not in good health. Nearly 70 percent of long-term uninsured adults who also reported being in poor health, and nearly 50 percent who reported being in fair health, said they could not see a physician when needed in the past year due to cost, as compared with 52 percent and 42 percent of short-term uninsured adults, and 22 percent and 16 percent of insured adults. "Long-term uninsured adults, particularly those in poor health or with chronic medical conditions, are a high-risk group for complications and early death, and many of these adults are not receiving the medical care they need," Ayanian says.
"Studies such as this one prove that living without insurance is a serious health risk that needs to be treated with the same sense of urgency as not wearing seatbelts or drunk driving," says Sandra Adamson Fryhofer, president of the American College of Physicians-American Society of Internal Medicine, the group that funded the study. "This evidence proves that preventive care is crucial to the health and well-being of the patient. Unfortunately, those without insurance often cannot get treatment for diseases such as diabetes, and consequently undergo unnecessary hospitalizations and more costly treatments."
Compounding this public health dilemma, smokers and binge drinkers were more often uninsured than adults without these risk factors. Further, for highly recommended preventive services, long-term uninsured adults were significantly less likely to receive mammography screening or Pap smears, hypertension and cholesterol testing, or colon cancer screening. Short-term uninsured adults had intermediate rates of unmet needs for preventive services that were statistically higher than the rates of insured adults for mammography, Pap smears, hypertension and cholesterol screening.
These findings, according to the study's authors, challenge the views expressed in national surveys that show a growing proportion of Americans-from 43 percent in 1993 to 57 percent 1999-believe uninsured people are able to get the care they need from physicians and hospitals. Further, the authors assert, failing to monitor or effectively treat chronic illnesses such as hypertension or diabetes in uninsured adults can result in substantial morbidity and may increase the nation's health care costs. The more intensive and expensive medical care used to treat preventable complications of chronic illnesses are absorbed by providers as free care, passed on to private insurers through cost shifting and higher fees, or paid for by taxpayers through higher taxes to finance public hospitals and public insurance programs.
The instrument used to conduct this study, the Behavioral Risk Factor Surveillance System (BRFSS), was created in 1984 and initially launched in 15 states. The BRFSS has collected data annually through telephone interviews of adults aged 18 years or older residing in households. Since 1994, all 50 states and the District of Columbia have administered the survey and submitted data to the Centers for Disease Control and Prevention. This study included adults aged 18 to 64 years from all 50 states and the District of Columbia who completed the 1997 and 1998 survey, including 105,764 respondents in 1997 and 117,634 in 1998. Respondents who reported having health insurance from any private or public source (including Medicare, Medicaid, and military or veterans' coverage) were classified as insured. Adults older than 64 were excluded because almost all are eligible for Medicare insurance.
Dr. Ayanian and the study's co-authors, Joel Weissman, PhD, Massachusetts General Hospital assistant professor of medicine, Eric Schneider, MD, MSc, Harvard School of Public Health instructor in medicine and health policy and management, Jack Ginsburg, MPE, American College of Physicians-American Society of Internal Medicine, and Alan Zaslavsky, PhD, Harvard Medical School associate professor of statistics, were funded by a grant from the American College of Physicians-American Society of Internal Medicine.