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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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92 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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94 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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96 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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98 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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00 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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02 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.

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