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4
The Difference Coverage
Could Make to the Health of
Uninsured Adults
Health insurance contributes independently and positively to the health of
adults and to the receipt of appropriate preventive services and care for chronic
and acute conditions. This overarching conclusion of the Committee rests on the
review and synthesis of research evidence presented in Chapter 3. These conclu-
sions take into account the methodological limitations of the largely observational
research that supports them, as discussed below.
This final chapter considers the broader implications of the Committee's
findings, including an assessment of the health-related benefits of insuring Ameri-
can adults who now lack health insurance coverage. What impact would health
insurance coverage have? Relating these findings to the U.S. uninsured popula-
tion as a whole depends on the characteristics of uninsured Americans, as well as
assumptions about the extent to which health insurance would improve the health
of those who lack coverage. Projecting or estimating the potential impacts of
health insurance on those who lack coverage also entails identifying the features
and mechanisms of health insurance promoting the receipt of care that effectively
improves health outcomes. This projection, or "what-if'' exercise, requires a
number of assumptions and careful linking of a sequence of inferences.
As detailed in Coverage Matters: Insurance and Health Care (IOM, 2001a), the 30
million American adults without health insurance are disproportionately young,
nonwhite, and members of lower-income families. About half of all uninsured
adults are between the ages of 18 and 35, a relatively healthy time of life.) The
iAlthough youth is not itself a risk factor for unmet health care needs, within every band of the age
spectrum some of those without health insurance are especially vulnerable. Among young adults,
those with special health needs who had coverage as dependents of their parents or through public
programs as disabled children and lost it upon reaching age 19, 20, or 21 are at greater risk of having
unmet health care needs (Fishman, 2001).
91
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CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE
other half are between 35 and 65 years of age. Although older adults are not
especially likely to be uninsured, being uninsured is especially risky for older adults
because of the much higher incidence of chronic and other illnesses in late middle
aged Approximately half of uninsured adults are non-Hispanic whites, more than
a quarter are Hispanic, one out of six are African American, and one out of twenty
are Asian American (IOM, 2001a). Almost two-thirds of uninsured adults have
just 12 years of schooling or less (IOM, 2001a), and half have family incomes
under 200 percent of the federal poverty level (Fronstin, 2001b). Most uninsured
adults (85 percent) either work or live in families where someone works at least
part time (Hoffman and Pohl, 2002~.
The causal link between health insurance coverage and better health out-
comes cannot be established conclusively by observational studies alone. The
studies reviewed in Chapter 3 that compare the health outcomes of insured and
uninsured populations, even with the extensive analytical adjustments that make
these comparisons more valid, do not answer definitively the question of whether
health insurance itself improves health outcomes. Nonetheless, the Committee
developed its conclusions based on the substantial consistency of results among the
methodologically strongest observational studies and the coherence of these results
with the behavioral research evidence that informs the Committee's conceptual
model of the mechanisms by which health insurance affects health outcomes (see
Figure 1.1~.
In order to understand the implications of the research evidence presented
here for the population of uninsured Americans, the Committee first considers the
findings of the previous chapter as they relate to specific groups within the overall
population of uninsured adults. Second, this chapter reviews the features of health
insurance plans that research indicates make a difference in health-related out-
comes for adults, information that is essential for designing effective policies to
extend insurance coverage. Last, the Committee considers the potential benefits
that could be achieved by providing health insurance coverage to uninsured
adults.
ADULTS MOST AT RISK OF POOR HEALTH
Chronically 111 Adults and the Risk Associated With Aging
Adults who have chronic illnesses face functional limitations and premature
death, consequences that might be ameliorated by appropriate health care. Chronic
illness and advancing age interact to increase vulnerability to the health effects of
being uninsured.
The prevalence of activity-limiting chronic conditions for the population
2Adults between ages 55 and 65 have an uninsured rate of 14 percent, somewhat below the overall
average (17.6 percent) and just half the rate for adults between ages 18 and 25 (Fronstin, 2001b).
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THE DIFFERENCE COVERAGE COULD MAKE
40
35
30
25
20
15
10
5
o
Activity-limiting
conditions
Fair or poor health
14.5
6.3
_ 5.1
1 1.5
37.0
21.1
18.5
26.1
18-44 45-54 55-64 65+
Age
93
FIGURE 4.1 U.S. population with activity-limiting chronic conditions (1998) and fair or
poor health (1999~.
SOURCE: NCHS, 2001, Tables 57 and 58.
under age 45 is relatively low and stable, at about 6 percent (NCHS, 2001~.3
Between ages 45 and 55, however, the rate of activity-limiting conditions more
than doubles, to 14.5 percent of the population, and it increases to 21 percent for
those between ages 55 and 65. For those ages 65 and older, more than one-third
(37 percent) have activity limitations due to chronic conditions (Figure 4.1~.
Likewise, the proportion of the population reporting fair or poor health increases
from 5 percent for those between ages 18 and 45 to 11.5 percent for those ages
45-54 and to 18.5 percent for those ages 55-64 (NCHS, 2001~. Fully one-quarter
of persons 65 and older report being in fair or poor health.
The appropriate use of health care services in screening, early diagnosis, and
disease management can reduce the burdens of disability and death due to chronic
3In the National Health Interview Survey, from which these data are reported, limitations of
activity refer to long-term reductions in the capacity to perform activities typical for persons in the
same age group as the respondent that are due to a chronic health condition. Such activities include
personal care (bathing, dressing, eating), walking, and remembering (NCHS, 2001).
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CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE
diseases such as cardiovascular disease, cancer, diabetes, depression, HIV infection,
kidney disease, and arthritis. Chronically ill persons without health insurance are
much less likely than those who are insured to have had a physician visit within
a year's time (odds ratio ~OR] = 0.5 in HaLner-Eaton, 1993; see also Fish-
Parcham, 2001~.
Except for those with end-stage renal disease (93 percent of whom have
Medicare coverage), chronically ill adults under age 65 are about as likely to be
uninsured as are their healthier counterparts. Medicare or Medicaid coverage for
disabled adults who reside in the community (i.e., are not in health care institu-
tions) extend to only some of those with chronic conditions. For persons under
age 65, 3 million of the 21 million persons under age 65 diagnosed with heart
disease, 2 million of the 14 million diagnosed with hypertension, and 1 million of
the 8 million diagnosed with arthritis lack health insurance (estimates based on the
1996 Medical Expenditure Panel Survey ~MEPS]) (Fish-Parcham, 2001~.4 Fully
one-quarter of lower-income (i.e., with family incomes less than 200 percent of
the federal poverty level) persons with heart disease, hypertension, or arthritis
lacked coverage (Fish-Parcham, 2001~.
As the U.S. population ages, both the numbers and the proportion of adults at
greater risk of developing health problems are increasing. While the 37.3 million
adults in the 55-64 age cohort now represent 8.7 percent of the U.S. population,
this age group is projected to grow 2.5 percent each year through 2015 to 61.9
million or almost 20 percent of the total population (Kinsella and Velkoff, 2001) .
Sixty percent of those workers between ages 55 and 65 who are uninsured, 1.3
million people, report having health problems, and one out of every five adults in
this age group, 4.8 million people, has at least one activity limitation due to a
chronic condition (Monheit et al., 2001; NCHS, 2001~. More than 900,000 adults
ages 55-64 in fair or poor health were uninsured in 1999 (Swartz and Stevenson,
2001~. Uninsured older adults are much less likely than their insured counterparts
to have a regular source of care or to receive cancer or heart disease screenings, as
illustrated in Table 4.1 (Powell-Griper et al., 1999~.
Older workers and their spouses who have health insurance coverage through
the workplace are increasingly at risk of loss of health insurance if they retire
before age 65, because employers are increasingly dropping retiree health benefits
and raising the costs to retirees of participating in those plans that have survived
(GAO, 1998; GAO, 2001a, 2001b; Fronstin and Reno, 2001~. Furthermore,
while older adults are more likely than young workers to purchase individual
insurance policies if they do not have access to workplace coverage, they are also
more likely to face higher premiums, benefits exclusions, and refusals of coverage
because of their age and health conditions (GAO, 2001a, 2001b; IOM, 2001a;
Monheit et al., 2001; Pollitz, 2001~. Older women particularly are at risk of not
4These condition-specific estimates count individuals with multiple conditions more than once.
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THE DIFFERENCE COVERAGE COULD MAKE
TABLE 4.1 Adjusted Odds Ratios for Uninsured Versus
Ages 55-64 Years for Selected Characteristics, 1993-1996
95
Insured U.S. Adults
Characteristics
Ad; usted
Odds Ratioa
95% Confidence
Interval
Health status good, very good, or excellent
Regular source of care
cost a barrier to care
Last routine checkup <2 years
Last Pap test <3 years
Last mammogram <3 years
Last clinical breast exam <2 years
Last blood pressure check < 2 years
Last cholesterol check < 5 years
0.79
0.25
7.58
0.25
0.38
0.27
0.32
0.21
0.35
0.68-0.93
0.19-0.33
6.46-8.91
0.21-0.28
0.31-0.46
0.23-0.32
0.26-0.39
0.16-0.29
0.28-0.43
Adjusted for sex, race, educational level, and marital status.
SOURCE: Adapted from Powell-Griner et al., 1999, Table 3.
having health insurance coverage, because of gender-related employment patterns
and a greater likelihood of obtaining coverage as a dependent of an older spouse,
who may lose access to spousal workplace coverage upon retirement (Meyer and
Pavalko, 1996~. For working women, ages 55-64 in good, fair, or poor health, 23
percent lack health insurance, compared with 10 percent of those in excellent or
very good health (Monheit et al., 2001~. In contrast, health insurance coverage
rates for working men in this age group do not vary by health status (Monheit et
al., 2001~.
Adults with Severe Mental Illnesses
Among chronically ill adults, those with a severe mental illness deserve special
attention when considering health insurance coverage because the issues of appro-
priate care and maintaining coverage are closely related for them.5 Almost 4.5
million Americans, 2.8 percent of adults over age 18, have a severe mental illness
(Narrow et al., 2000~. Persons with severe mental illness are more likely to have
5severe mental illnesses include schizophrenia, other psychoses, manic-depression (bipolar disor-
der), and severe forms of other disorders such as major depression (Narrow et al., 2000).
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CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE
alcohol and substance use disorders than are members of the general population
(U.S. Surgeon General, 1999; Narrow et al., 2000~.
Persons with chronic mental conditions that include behavioral and psychotic
symptoms, who reside outside institutions (including the homeless), may have
difficulty meeting the demands of daily living, especially functions such as main-
taining employment or health insurance (Pollack and Kronebusch, 2001~. A1-
though many persons with severe mental illnesses qualify for Medicare or Medic-
aid as disabled, their condition may make it difficult for them to maintain
continuous coverage through Medicaid, which requires periodic requalification
(Bazelon/Milbank, 2000~. An estimated 45 percent of persons with a severe
mental illness have public insurance. However, even with this relatively high rate
of public insurance coverage, 20 percent of adults with a severe mental illness
remain uninsured (McAlpine and Mechanic, 2000~.
Despite having a serious and chronic condition, only 40-60 percent of per-
sons with a severe mental illness receive any outpatient treatment within a given
year (McAlpine and Mechanic, 2000; Narrow et al., 2000~. Lacking health insur-
ance is the most commonly reported barrier to receiving care for persons with
mental illness (Druss and Rosenheck, 1998~. In addition, persons with severe
mental illness face exceptional difficulties in obtaining health care apart from
mental health services and are more likely to die prematurely from physical con-
ditions than are persons without mental diagnoses (Druss et al., 2001; Jeste and
Unuetzer, 2001~.
Persons of Lower Socioeconomic Status and Members of
Racial and Ethnic Minorities
Adults with lower educational attainment and lower incomes use fewer health
services and have worse health outcomes than do better-educated and higher-
income adults, and they are also more likely to be uninsured (Preston and Elo,
1995; IOM, 2001a; Shi, 2001~.6 Lower-income persons tend to be uninsured for
longer periods than higher-income persons, which increases their risk of poorer
health-related outcomes, as discussed in the previous chapter (McBride, 1997;
IOM, 2001a). Adults in lower-income families are also substantially more likely to
have experienced recent gaps in health insurance coverage as well as being more
likely to be uninsured at a given point in time, as illustrated in Figure 4.2 (Hoffman
et al., 2001~.
African Americans and Hispanics face greater barriers to health care and
poorer health outcomes than do non-Hispanic whites and are more likely to lack
health insurance, with two and three times the uninsured rate, respectively, of
non-Hispanic whites (IOM, 2001a). Among the uninsured who are in families
6Lower income is defined as having a family income below 200 percent of the federal poverty level
or $34,100 for a family of four in 2000.
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THE DIFFERENCE COVERAGE COULD MAKE
70 -
60 ~
50 ~
a, 40 -
-
30 ~
20 ~
10 ~
O
97
1 l Currently unit
~ Recent gap a
$20,000 or less $20,001-35,000 $35,001-60,000
Family Income
More than
$60,000
FIGURE 4.2 Percentage of adults in working families who were uninsured within the
past two years, by income. aPerson was insured at the time of the survey but had a period
in the past two years without coverage.
SOURCE: Hoffman et al., 2001, Figure 1. Based on the Kaiser/Commonwealth 1997
National Survey of Health Insurance.
with incomes below the federal poverty level (about $17,000 for a family of four
in 2000), about 40 percent are members of racial and ethnic minority groups
(Mills, 2001~. The lack of health insurance thus converges with other risk factors
Cow socioeconomic status tSES] and minority status) to reduce the likelihood of
receiving needed care (IOM, 2001a; Shi, 2001~. Although lack of health insurance
is only one of several factors that contribute to socioeconomic and ethnic dispari-
ties in health, it is an important component and is one of the most amenable to
intervention. Health insurance more strongly and consistently influences health
care utilization than it does health status. While health insurance may alleviate
financial barriers to care and improve the choice of providers, it does not address
other individual and societal determinants of poor health and disparate care that
are experienced by ethnic minorities and the economically disadvantaged. These
include low literacy skills that may interfere with the ability to understand instruc-
tions or participate in medical decisions, health beliefs, life-style practices, and
environmental influences (Haas and Adler, 2001~. In addition, health care provid-
ers are not uniformly competent in cross-cultural communication, and this, along
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CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE
with a history of overt racial discrimination, may result in less effective provider-
patient interactions (Haas and Adler, 2001; IOM, 2002~. Thus, although health
insurance by itself will not eliminate ethnic and socioeconomic disparities in
health, it may reduce such disparities and improve health-related outcomes for
minority and economically disadvantaged groups.
Multiple Jeopardy
The health risks of being uninsured are not randomly distributed throughout
the U.S. population, nor are they randomly distributed among the population of
uninsured adults. Many of the uninsured belong to one or more of the higher-risk
groups just discussed. For these individuals, lacking health insurance represents a
more immediate threat to their health and personal well being (Shi, 2001~.
The greater risks of poor health for adults in late middle age, those of lower
SES, and members of racial and ethnic minority groups make health insurance
even more important for these multiply disadvantaged groups because coverage
and health services can make more of a positive difference. A corollary of this is
that studies of the impact of health care on health outcomes that are based on
broader populations may not fully reflect its significant impact on particular sub-
populations at heightened risk of poor health outcomes. When these subpopula-
tions are examined separately however, the impact of health care and coverage
becomes apparent.
For example, the RAND Health Insurance Experiment demonstrated that
persons with lower incomes and worse health status are most affected by cost-
sharing requirements. Lower-income adults with hypertension who faced no cost
sharing had better blood pressure control than those in plans with any amount of
cost sharing. In contrast, overall, the experiment did not find differences in most
health outcomes related to cost sharing (Brook et al., 1983; Keeler et al., 1985;
Newhouse et al., 1993~. Similarly, in a small "natural experiment" among low-
income adults in California, the loss of Medi-Cal coverage was accompanied by
diminished overall health status and, for those with hypertension, by markedly
poorer blood pressure control after six months and one year (Lurie et al., 1984,
1986~.7 Although these larger effects of health insurance on vulnerable popula-
tions are diluted in broader, population-based studies, they are present in the
results of the research presented in Chapter 3.
FEATURES OF HEALTH INSURANCE THAT
IMPROVE HEALTH-RELATED OUTCOMES
Health insurance has different effects depending on the kind and conditions of
coverage. With the exception of the RAND Health Insurance Experiment, the
7Both of these studies are discussed more fully in Chapter 3.
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THE DIFFERENCE COVERAGE COULD MAKE
99
literature review excluded studies that examined patterns of health care use and
outcomes only among insured populations. Thus, for example, the Committee's
findings do not include comparisons between fee-for-service and managed care
plans. Although scope of benefits was not the primary focus of this review, studies
of several chronic conditions and utilization of screening services suggest that the
magnitude of the health insurance effect is related to the benefits covered. Fur-
thermore, some of the differences reported among those covered by Medicaid,
Medicare, and private health insurance can be attributed to differences in the
scopes of benefits under these alternative forms of coverage.
Regular Source of Care and Continuity of Coverage
A continuing relationship with a primary provider or system of care is a
hallmark of quality health care (IOM, 2001b). Health insurance is effective in
improving receipt of appropriate health care in part because it increases access to a
regular source of care. Many of the studies reviewed in the previous chapter,
particularly in the management of chronic disease and preventive care, confirmed
that more appropriate utilization and better outcomes for insured adults could be
accounted for by the greater likelihood of having a regular source of care com-
pared to uninsured adults and those with a recent gap in coverage. Stable health
insurance coverage maintains access to a regular source of care over time.
Having health insurance coverage that does not afford access to a regular
source of care for any reason (e.g., geographical scarcity, restricted provider pools,
inadequate provider participation) may result in outcomes for insured adults that
differ little from those for uninsured adults. Having health insurance with frequent
breaks in coverage that disrupt access to a regular source of care is also less effective
in improving health-related outcomes than is continuous coverage (Lurie et al.,
1986; Burstin et al., 1998; Hoffman et al., 2001~. In particular, Medicaid enrollees
may have inadequate access to a regular source of care both because of insufficient
provider participation and because enrollment in Medicaid tends to be sporadic, as
discussed below.
The performance of health insurance plans and programs in facili-
tating a regular and continuing care relationship for enrollees should be
a key factor in the design of any health insurance coverage reform.
Scope of Benefits
The scope of health insurance benefits also influences how coverage affects
health-related outcomes. As noted in Chapter 1, there is no standard or calibrated
"dose" of health insurance across the studies that examine health insurance effects.
Private health insurance plans vary widely in terms of their benefits, cost-sharing
provisions, and conditions by which providers participate in them (IOM, 2001a).
They may or may not cover preventive services, prescription drugs, or specialty
mental health services; impose substantial deductible or coinsurance requirements;
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CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE
restrict access to specialists; or require each enrollee to have a primary care pro-
vider.
Coverage of preventive services, prescription drugs, and mental health ser-
vices varies considerably among health insurance plans. These services, however,
are critical elements of appropriate health care that can improve outcomes for
conditions such as cancer, cardiovascular disease, diabetes, HIV infection, and
depression. Chronically ill adults whose conditions require pharmaceutical thera-
pies are more likely to follow their treatment regimens if they have insurance
coverage for prescription drugs (Huttin et al., 2000~.
The distinctive benefit packages of public health insurance programs affect
the outcomes that have been reviewed here. For example, the superior results for
Medicaid and Medicare enrollees with respect to mental health care may be
attributed to the more extensive coverage of these services than that available
under many private insurance plans. Also, the coverage of preventive services and
prescription drugs by Medicaid may account for the more appropriate receipt of
screenings and chronic disease care, comparable to that for those enrolled in
private health plans, by those enrolled in Medicaid.
Ease of access to providers is another aspect of plan benefits that affects the
impact of health insurance coverage on outcomes. These considerations apply to
both public and private insurance programs and plans. Access may be administra-
tively restricted (e.g., with appointment protocols) or enhanced (e.g., with assign-
ment of a specific primary care provider) within managed care plans. Payment
rates and arrangements also affect the willingness of providers to participate and,
consequently, affect the access of enrollees to care. Adequate access to providers,
under both managed care and fee-for-service programs, is particularly problematic
within some Medicaid programs, as discussed in the following section.
The Special Case of Medicaid
As evident in several individual study results for overall health status, cancer
outcomes, and hospital-based care, adults with Medicaid coverage frequently fare
no better and sometimes fare worse than uninsured patients in their health-related
outcomes, even when observations are adjusted for demographic factors and health
status at the beginning of the study period. Two factors contribute to the distinc-
tive outcomes for Medicaid enrollees: the structure and operation of Medicaid as
an insurance program and the characteristics of the population that qualifies for
Medicaid coverage.
The programmatic features of Medicaid that contribute to worse health-
related outcomes among its enrollees include provider participation and payment
levels and limited coverage periods. Low provider payment rates, in both the fee-
for-service and the capitated sectors, reduce access to health care services for
Medicaid enrollees in many states and localities (IOM, 2000a). (Medicaid payment
levels and conditions of provider participation vary among states, as do health
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THE DIFFERENCE COVERAGE COULD MAKE
10
sector services and resources more generally.) Medicaid enrollees often find
themselves limited to much the same set of overtaxed safety-net providers as
uninsured adults, with concomitant delays in getting appointments and referrals to
specialists and little continuity of care (IOM, 2000a). Medicaid's limited coverage
periods also weaken any positive effects of insurance. Medicaid coverage tends to
be intermittent, with adults gaining or losing coverage as their income, employ-
ment, or health status changes (McBride, 1997; Davidoff et al., 2001~. In one
recent study based on the federal Survey of Income and Program Participation, the
median length of time that adults under age 65 maintained Medicaid enrollment
was just five months (Tin and Castro, 2001~. In some states, Medicaid requires
eligibility redeterminations as frequently as monthly, and some people lose cover-
age simply because they did not meet administrative requirements. As a conse-
quence of the intermittency of Medicaid coverage, adults identified as covered by
Medicaid at one point in time may not achieve the benefits that continuous health
. · ~
insurance coverage can provide.
The second aspect that contributes to the worse outcomes of Medicaid en-
rollees its distinctive eligibility criteria is discussed in Chapter 2 (see Box 2.1~.
Adults who are eligible for Medicaid are low income and often are either disabled
or incur significant health care expenses. Each of these factors is associated with
relatively poor health status. Furthermore, among all adults who are eligible for
Medicaid coverage, those who actually enroll in the program are likely to be those
who have already had encounters with the health care system (Davidoff et al.,
2001~. This operational feature of Medicaid can distort the results of studies of
insurance status and outcomes. For example, a Medicaid enrollee being treated for
breast cancer may have developed the disease long before enrolling in Medicaid,
yet her late-stage cancer diagnosis, a worse outcome, is attributed to the publicly
insured (rather than uninsured) group if cancer registry or hospital records identify
her as covered by Medicaid at the time of diagnosis (Perkins et al., 2001~.
Medicaid coverage is not worse than no coverage at all, as a facile review of
study results might suggest. Medicaid is a program with structural features that
limit its ability to deliver to enrollees all of the potential benefits of health insur-
ance coverage and it serves adult populations with multiple health risks.
INSURING THE UNINSURED: IMPROVING
HEALTH OUTCOMES
How would health care utilization and health outcomes be affected by pro-
viding adults who now lack coverage with health insurance? What can we learn
from the largely observational body of research on the impact of health insurance
on utilization and outcomes about the impacts of providing those Americans who
are most at risk of lacking health insurance with such coverage? First, we can
expect that upon gaining coverage, uninsured adults would
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CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE
· use more health care services,
. . .
· receive more appropriate preventive care, and
· better manage their chronic conditions.
Health insurance would improve the chances that currently uninsured adults
would have a regular source of care. Providers would be more likely to provide
appropriate services to a patient with a condition of given severity if that patient
had health insurance, but could also be more likely to provide services that were
not clearly clinically indicated.8 Most importantly, if adults who now lack
health insurance were to be insured on a stable and ongoing basis, their
health status would likely be better than it would be without health
insurance, and their risk of dying prematurely would be reduced.
The Committee recognizes that health insurance alone will not eliminate
disparities in access to health care among the population now without health
insurance nor will it equalize health outcomes among socioeconomically diverse
groups. Such disparities persist in countries such as Great Britain and Canada that
do have universal health insurance programs (Marmot et al., 1991; Hamilton et al.,
1997; Ho et al., 2000~. See Boxes 2.2 and 2.3 for further discussion of disparities
related to race and ethnicity and SES. Nevertheless, health insurance is associated
with better physical functioning, health status, and health-related quality of life
(Baker et al., 2001; Franks et al., 1993b; Cunningham et al., 1995; Penson et al.,
2001~. Health insurance is also associated with better survival, both overall and for
adults with specific conditions such as cancer, cardiovascular diseases, and HIV
infection. Appendix D presents estimates for the U.S. population as a whole ofthe
differential mortality risks for adults with and without health insurance, as illustra-
tive of the potential reductions in mortality among uninsured adults that could
follow from insuring the entire U.S. population.
However, the survival benefits of having health insurance coverage can be
achieved fully only when health insurance is acquired well before the develop-
ment of advanced disease. The problem of later diagnosis and higher mortality
among uninsured women with breast cancer, for example, cannot be solved by
insuring women once their disease is diagnosed. Greater use of preventive ser-
vices, early detection of disease, and effective, continuous management of health
conditions account for many of the benefits that health insurance provides its
enrollees. A patient with an ongoing relationship with a health care provider is
more likely to receive appropriate medical attention and services early in the
development of an illness or disease process rather than only once the condition
8This conclusion is supported by the findings in Chapter 3, particularly those for hospital-based
care (including cardiovascular disease and trauma treatments). See also, "Physician Response to Pa-
tient Insurance Status in Ambulatory Care Clinical Decision-Making" (Mort et al., 1996) for primary
care physicians' responses to hypothetical clinical scenarios that included information about the patient's
insurance status.
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THE DIFFERENCE COVERAGE COULD MAKE
103
has become acute or difficult to treat. Insurance coverage can facilitate such a
relationship and provide the financial means for patients and their provider of first
contact to obtain beneficial health care services. The Committee concludes
that broad-based health insurance strategies across the entire uninsured
population would be more likely to produce the benefits of enhanced
health and life expectancy than would "rescue" programs aimed only at
the seriously ill.
Finally, the evidence presented in this report accounts for only some of the
benefits and advantages that health insurance provides. The Committee's first
report, Coverage Matters, identified financial risk reduction and economic security
as major benefits of health insurance that accrued to everyone with coverage,
whether or not they happened to use it. These considerations will be examined
again from the standpoint of family well being in the Committee's next report.
This research review did not examine patient satisfaction or quantify the sense
of being valued when professional and caring attention is provided in painful,
stressful, or frightening circumstances. Yet these less tangible qualities are just as
real as improvements in survival rates. Furthermore, they are more likely to be
achieved in health care settings and healing relationships in which people may
confidently make a claim on health care providers' time and resources. Adults
without health insurance are less likely to feel entitled to a provider's attention
when they seek care and indeed, uninsured adults are less likely to seek needed
care than are those with health insurance (Kaiser Commission, 2000~.9
Thus, although this report has focused almost entirely on health-related out-
comes, the most quantifiable and extensively measured personal consequences of
health insurance, they account for only some of the benefits of coverage. 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 benefits that accrue to members of our society who have
health insurance. For many of the 40 million uninsured Americans, these benefits
remain out of reach.
9See Ferrer (2001), for an account of the circumstances under which uninsured persons obtain care
in overtaxed safety-net facilities that supports these points.
OCR for page 104
Representative terms from entire chapter:
insurance coverage
