Published by the Institute of Medicine, Committee
on the Consequences of Uninsurance,
National Academy of Sciences, Washington, DC, May, 2002.
For More Information…
Visit the Committee’s website at www.iom.edu/uninsured.
Copies of Care Without Coverage: Too Little, Too Late are available
for sale from the National
Academy Press; call (800) 624-6242 or (202) 334-3313 (in the Washington
metropolitan area), or
visit the NAP home page at www.nap.edu.
This study was funded by The Robert Wood Johnson Foundation.
The Institute of Medicine is a private, nonprofit organization that
provides health policy advice
under a congressional charter granted to the National Academy of
Sciences. For more information
about the Institute of Medicine, visit the IOM home page at www.iom.edu.
Copyright ©2002 by the National Academy of Sciences. All rights
reserved.
Permission is granted to reproduce this document in its entirety,
with no additions or alterations.
In the United States, too many working-age people lack insurance cover-age and when they do get necessary medical care, it is too little and too late. One national study found that, over a 17-year follow-up period, adults who lacked health insurance at the outset had a 25 percent greater chance of dying than did those who had private health insurance. Health insurance is a key that provides access to high quality health care and consequently to better health. It is not the only key that opens these doors nor is access to them guaranteed if one has coverage. But health insurance is the mechanism that most Americans rely upon to obtain the care that they want and need. The health benefits of insurance are strongest when coverage is continuous rather than sporadic.
This report, the second in a series issued by the Institute of Medicine
(IOM) Committee on the Consequences of Uninsurance, summarizes the research
evidence contrasting the health of insured and uninsured adults. The
main findings are that working-age Americans without health insurance
are more likely to:
•Receive too little medical care and receive it too late;
•Be sicker and die sooner;
•Receive poorer care when they are in the hospital even for acute situations like a motor vehicle crash.
The health and length of life of working-age Americans would improve if they obtained coverage. Like those who are now insured, the newly insured would use preventive services more often and would be less likely to delay seeking care, thus making early detection and treatment of problems more feasible. The best health outcomes are possible only if the uninsured obtain coverage before the onset of any illness or injury.
•Go without cancer screening tests, delaying diagnosis and leading to pre-mature death;
•Do not receive care recommended for chronic diseases, like timely eye and foot exams to prevent blindness and amputations in persons with diabetes;
•Lack regular access to medications to manage conditions such as hypertension or HIV infection;
•Receive fewer diagnostic and treatment services after a traumatic injury or a heart attack, resulting in an increased risk of death even when in the hospital.
Assessing the Impact of Health Insurance on Health-Related Outcomes
The Committee reviewed 130 research studies that consider (1) health insurance status as an independent variable, and (2) its effect on health-related out-comes for adults ages 18 through 64. Studies focusing on older adults were excluded because virtually all have coverage through Medicare. The next Committee report will review the effects of coverage for children and pregnant women. For this report, “insured adults,” means those with general medical and hospitalization insurance while “uninsured adults” are without any health insurance.
Most of the evidence about the value of coverage comes from observational
rather than experimental studies. Therefore, research studies adjust for
variations among study subjects in types of health insurance coverage and
characteristics of study participants. Three personal characteristics—health
status, race and ethnic
identity, and socioeconomic status—are closely related to both having
health insurance and the source of coverage. The most informative studies
separate the effects of these personal characteristics from those attributable
to having coverage.
Effects of Health Insurance on Health
The quality and length of life are distinctly different for insured
and uninsured populations. Even the most acutely ill or seriously injured
adults, when uninsured, cannot always obtain needed care. Having health
insurance will not just increase access in times of crisis but will also
facilitate use of essential health screening
services and chronic disease care.
Health insurance does not eliminate all racial and ethnic disparities in health. This is confirmed by this study as well as by the recent IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. However, having insurance does facilitate access to preventive services, a regular source of care, and better quality care for minority populations.
Primary Prevention and Screening Services
Uninsured adults are less likely than insured adults to receive recommended
health screening services (e.g., mammograms, clinical breast exams, Pap
tests, colorectal screenings). And when they do receive these preventive
services, it is not as often as recommended by the U.S. Preventive Services
Task Force. The
disparities in whether someone uses these vital services holds even
after accounting for the possible influence of age, race, education or
having a regular source of care.
Some health insurance plans cover preventive health care and others
do not. If your plan covers preventive services, you are more likely to
get them, particularly if the service is costly, like a mammogram. If your
plan does not cover preventive services, you are still more likely to receive
preventive services than anyone who
is uninsured. Why? Most people with insurance have a regular medical
provider who looks out for their health.
Cancer Care and Outcomes
Uninsured cancer patients generally have poorer outcomes and die
sooner than persons with insurance. Without timely preventive screenings,
diagnosis is delayed. As a result, when cancer is found, it is relatively
advanced and more often fatal than it is in persons with health insurance
coverage. For example, uninsured
women with breast cancer have a 30 to 50 percent higher risk of
dying than women with private health insurance. Furthermore, once diagnosed,
treatment disparities persist. For example, uninsured women are less likely
to receive breast-conserving surgery.
Chronic Disease Care and Outcomes
Uninsured adults are less likely to have regular checkups and a usual source of care to help manage their disease than is a person with coverage. For the five chronic 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.
Cardiovascular Disease: Despite the fact that having a usual source of care improves medical management, 19 percent of uninsured adults diagnosed with heart disease and 13 percent with hypertension lack this ongoing relationship. Their blood pressure and cholesterol levels are monitored less frequently, and they are less likely to begin or stay on drug therapy than insured adults. These deficits in care place the uninsured at further risk of deteriorating health. For example, studies in emergency departments show that patients admitted with severe uncontrolled hypertension are disproportionately uninsured.
End-Stage Renal Disease (ESRD): The clinical goals for treatment
of kidney disease are to slow the progression of renal failure, and prevent
or manage complications and co-existing diseases (e.g., heart disease).
Uninsured patients have more severe renal failure when they begin dialysis,
and their health is often already compromised because they did not receive
treatment for anemia before initiating dialysis. Virtually all ESRD patients
qualify for Medicare once dialysis or transplantation becomes necessary.
What is the effect of obtaining this insurance? Differences in the care
received by women and men and by members of different
racial and ethnic groups (for example, hospital-based treatments
for heart disease) among patients with kidney disease are essentially eliminated.
Human Immunodeficiency Virus (HIV) Infection: One positive
effect of health insurance for HIV-infected adults is obtaining a regular
source of care. Without health insurance, many wait more than three months
after diagnosis to have their first office visit. The uninsured wait an
average of four months longer than privately
insured patients to receive newer drug therapies. Once started on
medications, the uninsured are less able to maintain the necessary but
costly and complicated drug regimen. Having health insurance appears to
reduce mortality in HIV-infected adults by 71-85 percent over a 6-month
period. The greatest reductions in mortality were found more recently when
effective drug therapies came into widespread use.
Mental Illness: Mental illness represents a major but often underestimated source of disability. It contributes as much to disability as does cancer or heart disease. As is the case with other diseases, the uninsured are less likely than those with coverage to receive the desirable level of mental health care.
Without specific coverage for mental health visits, patients diagnosed with depression, panic disorder, or generalized anxiety disorder are less likely to receive mental health services. Having general health insurance, even without mental health benefits, increases the likelihood of receiving some care and that the care meets professional practice guidelines.
Severe mental illnesses (schizophrenia, other psychoses and bipolar
depres-sion) require the attention of specialty mental health professionals
and perhaps more extensive services (e.g., inpatient services, partial
or day hospitalization). Persons with a severe mental illness face difficulties
in obtaining and then keeping
insurance after diagnosis. They also experience delays in obtaining
specialty mental health services and receive less appropriate care until
they qualify for public insurance coverage (Medicare or Medicaid). Notably,
those with public insurance are more likely to receive specialty services
than are severely ill persons with private insurance, which may have more
restrictive benefits.
Hospital-based Care
The poorer health status of uninsured adults at the time of hospitalization
is compounded by experiences as inpatients. They receive fewer needed services,
worse quality care, and have a greater risk of dying in the hospital or
shortly after discharge. For example, uninsured patients are less likely
to receive an endoscopy
and, when they finally do receive it, the pathology is more likely
to be abnormal. Because the uninsured are more likely to delay seeking
care, their risks of poor outcomes are greater (e.g., rupture in acute
appendicitis).
Acute Cardiovascular Disease: Uninsured patients with acute cardiovascular disease are:
•less likely to receive angiography or revascularization procedures,
•less likely to be admitted to a hospital that performs these diagnostic and treatment procedures, and
•more likely to die in the short term.
Health insurance not only improves access, but it also lessens disparities in cardiovascular procedures between men and women and among racial and ethnic groups.
General Health Outcomes
What happens to adults’ health when they remain uninsured? It depends on a person’s age, underlying health, and the length of time uninsured. Adults in late middle age (especially between 55 and 65 years of age) and adults with low incomes are particularly susceptible to deteriorating health if they never had or lose health insurance coverage.
Relatively short (1-4 year) longitudinal studies document decreases in general health for adults who are uninsured or lose coverage. Changes may include worsening control of blood pressure, decreased ability to walk or climb stairs, reduced overall self-perceived wellness and ability to perform daily activities.
Longer population-based studies (over 5 to 17 years) show that adults under age 65 who were uninsured at the beginning of the study face a 25 percent higher risk of dying than those with private coverage. This pattern is found when comparing deaths of uninsured and insured patients from heart attack, cancer, traumatic injury, and HIV infection.
The Difference Coverage Could Make to the Health of Uninsured Adults
Uninsured adults with a heart attack have a greater chance of dying in the hospital or shortly after release than those who have private insurance.
CONCLUSIONS
•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 experience greater declines in health status and die sooner than do adults with continuous coverage.
•Adults with chronic conditions and those in late middle age stand to benefit the most from health insurance coverage in terms of improved health outcomes because of their generally greater need for health care.
•Racial and ethnic minorities and lower-income adults would particularly
benefit from increased health insurance coverage because they more often
lack stable health insurance coverage and have worse health status. Increased
coverage would likely reduce some of the racial and ethnic disparities
in use of appropriate
health care services and may also reduce disparities in morbidity
and mortality.
•Health insurance that ensures adequate provider participation and that includes preventive and screening services, outpatient prescription drugs and specialty mental health care is more likely to facilitate the receipt of appropriate care.
•Broad-based health insurance strategies across the entire uninsured population would be more likely to produce these benefits than would “rescue” programs aimed only at those who are already seriously ill.
The survival benefits derived from insurance coverage, however, can be achieved in full only when health insurance is acquired well before the development of advanced disease. For example, insuring women once cancer is diagnosed will not solve the problem of later diagnosis and higher mortality among uninsured women with breast cancer.
Finally, the evidence presented only accounts for some of the advantages
that health insurance provides. Financial security and stability, peace
of mind, alleviation of pain and suffering, improved physical function,
disabilities avoided or delayed, and gains in life expectancy constitute
an array of health insurance benefits
that accrue to members of our society with health insurance. For
many of the 30 million uninsured adults and another 9 million children
in America, these benefits remain elusive.
For More Information…
Visit the Committee’s website at www.iom.edu/uninsured.
Copies of Care Without Coverage: Too Little, Too Late are available
for sale from the National
Academy Press; call (800) 624-6242 or (202) 334-3313 (in the Washington
metropolitan area), or
visit the NAP home page at www.nap.edu.
This study was funded by The Robert Wood Johnson Foundation.
The Institute of Medicine is a private, nonprofit organization that
provides health policy advice
under a congressional charter granted to the National Academy of
Sciences. For more information
about the Institute of Medicine, visit the IOM home page at www.iom.edu.
Copyright ©2002 by the National Academy of Sciences. All rights
reserved.
Permission is granted to reproduce this document in its entirety,
with no additions or alterations.
COMMITTEE ON THE CONSEQUENCES OF UNINSURANCE
MARY SUE COLEMAN (Co-chair), President, Iowa Health System and University
of Iowa,
Iowa City
ARTHUR L. KELLERMANN (Co-chair), Professor and Chairman, Department
of Emergency
Medicine, Director, Center for Injury Control, Emory University
School of Medicine, Atlanta,
Georgia
RONALD M. ANDERSEN, Wasserman Professor in Health Services, Chair,
Department of Health
Services, Professor of Sociology, University of California, Los
Angeles, School of Public
Health
JOHN Z. AYANIAN, Associate Professor of Medicine and Health Care
Policy, Harvard Medical
School, Brigham and Women’s Hospital, Boston, Massachusetts
ROBERT J. BLENDON, Professor, Health Policy & Political Analysis,
Department of Health
Policy and Management, Harvard School of Public Health and Kennedy
School of Government,
Boston, Massachusetts
SHEILA P. DAVIS, Associate Professor, The University of Mississippi
Medical Center, School of
Nursing, Jackson, Mississippi
GEORGE C. EADS, Charles River Associates, Washington, D.C.
SANDRA R. HERNÁNDEZ, Chief Executive Officer, San Francisco Foundation, California
WILLARD G. MANNING, Professor, Department of Health Studies, The
University of Chicago,
Illinois
JAMES J. MONGAN, President, Massachusetts General Hospital, Boston, Massachusetts
CHRISTOPHER QUERAM, Chief Executive Officer, Employer Health Care
Alliance
Cooperative, Madison, Wisconsin
SHOSHANNA SOFAER, Robert P. Luciano Professor of Health Care Policy,
School of Public
Affairs, Baruch College, New York
STEPHEN J. TREJO, Associate Professor of Economics, Department of
Economics, University of
Texas at Austin
REED V. TUCKSON, Senior Vice President, Consumer Health and Medical
Care Advancement,
UnitedHealth Group, Minnetonka, Minnesota
EDWARD H. WAGNER, Director, W.A. McColl Institute for Healthcare
Innovation, Group
Health Cooperative Puget Sound, Seattle, Washington
LAWRENCE WALLACK, Director, School of Community Health, College of
Urban and Public
Affairs, Portland State University, Oregon
IOM Staff
Wilhelmine Miller, Project Co-director
Dianne Miller Wolman, Project Co-director
Lynne Page Snyder, Program Officer
Tracy McKay, Research Associate
Ryan Palugod, Senior Program Assistant
Top of Page - Clinical Freedom Home Page - Freedom of Choice Medical Care - Current Events -