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OCR for page 197
America’s Uninsured Crisis: Consequences for Health and Health Care
Appendix E
Recent Studies of the Impacts of Health Insurance for Adults: Summary Table
A table summarizing quasi-experimental studies since 2002 on the impacts of health insurance on health outcomes of adults in the United States is presented in this appendix. The table was originally presented in a literature review commissioned by the Institute of Medicine Committee on Health Insurance Status and Its Consequences in 2008 titled Health Consequences of Uninsurance Among Adults in the United States: An Update, by J. Michael McWilliams, M.D., Ph.D., Harvard Medical School.
Several abbreviations are used in the tables:
HRS = Health and Retirement Study
MEPS = Medical Expenditure Panel Survey
NCHS = National Center for Health Statistics
NHIS = National Health Interview Survey
NIS = National Inpatient Sample
NPHS = National Population Health Survey
SEER = Surveillance, Epidemiology, and End Results
SSA = Social Security Administration
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TABLE E-1 Recent Quasi-Experimental Studies of the Effects of Health Insurance Coverage on Adults’ Health Outcomes, 2002-2008
Study
Data
Methodological Approach
Card et al. (2004)
The impact of nearly universal coverage on health care utilization and health: Evidence from Medicare
Cross-sectional survey data from the 1992-2001 NHIS; mortality data from NCHS Multiple Cause of Death files
Regression discontinuity analysis of general health status by age
Card et al. (2007)
Does Medicare save lives?
Cross-sectional state hospital discharge data from California from 1992-2002
Regression discontinuity analysis of mortality by age among acutely ill adults hospitalized for non-deferrable conditions
Decker and Rapaport (2002)
Medicare and inequalities in health outcomes: The case of breast cancer
SEER cancer registry data from 1980-1994 with followup mortality data
Difference-in-differences comparisons of stage of diagnosis and survival for white and black women with breast cancer before and after age 65
Decker (2005)
Medicare and the health of women with breast cancer
SEER cancer registry data from 1980-2001 with followup mortality data
Difference-in-differences comparisons of stage of diagnosis and survival for white, black, and Hispanic women with breast cancer before and after age 65
Decker and Remler (2004)
How much might universal health insurance reduce socioeconomic disparities in health?
Cross-sectional survey data from the 1997-1998 NHIS and the 1996-1997 NPHS
Difference-in-differences-in-differences comparison of general health status by age in the United States and Canada
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America’s Uninsured Crisis: Consequences for Health and Health Care
Principal Findings*
Limitations
Medicare eligibility after age 65 associated with significant 12% reduction in sociodemographic disparity in general health status but no evidence of deceleration in mortality rates at age 65
Comparisons by prior insurance status or pre-existing conditions not possible with cross-sectional data; only one self-reported general health outcome assessed; differential changes in health trends not assessed; regression discontinuity design not suited for identification of delayed mortality effects in general population
Medicare eligibility after age 65 associated with abrupt absolute decrease in 7-day mortality of 1% (20% relative reduction) that persisted for at least 2 years after admission
Comparisons by prior insurance status not possible with cross-sectional data; alternative explanations for survival gains could not be tested directly
Medicare eligibility after age 65 associated with significant decrease in probability of late detection for white women but not black women; coverage estimated to increase 5-year survival rate for both black and white women diagnosed with early stage disease, but differential effect for black women not significant
Comparisons by prior insurance status not possible; persistent racial and ethnic disparities in outcomes among insured adults may have reduced differential effects; outcomes assessed for breast cancer only
Medicare eligibility after age 65 associated with absolute decrease of 3.4% in probability of late detection for Hispanic women and 1.8% decrease for white women, but differential effect not significant; 11% relative reduction in mortality risk after age 65 did not differ by race or ethnicity
Comparisons by prior insurance status not possible; persistent racial and ethnic disparities in outcomes among insured adults may have reduced differential effects; outcomes assessed for breast cancer only
Medicare eligibility after age 65 associated with a significant differential reduction of 4.0 percentage points (se = 1.9) in probability of fair or poor health for low-income U.S. adults; socioeconomic disparity in general health among nonelderly adults reduced by more than half
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America’s Uninsured Crisis: Consequences for Health and Health Care
Study
Data
Methodological Approach
Dor et al. (2006)
The effect of private insurance on the health of older, working age adults: Evidence from the Health and Retirement Study
Longitudinal survey data from the 1992-1998 HRS
Instrumental variables analysis using state-level marginal tax rates, unemployment rates, and unionization rates as instruments for health insurance coverage
Finkelstein and McKnight (2005)
What did Medicare do (and was it worth it)?
Mortality data from NCHS Multiple Cause of Death files
Difference-in-differences comparisons of mortality before and after 1965 by age (young elderly who became covered by Medicare vs. near-elderly who did not) and by geographic variation in insurance rates prior to 1965
Hadley and Waidmann (2006)
Health insurance and health at age 65: Implications for medical care spending on new Medicare beneficiaries
Longitudinal survey data from the 1992-1998 HRS
Instrumental variables analysis using spouse’s prior union status, immigrant status and years in the Unied States, and involuntary job loss as instruments for health insurance coverage
Lichtenberg (2002)
The effects of Medicare on health care utilization and outcomes
Cross-sectional survey data from the 1987-1991 NHIS; vital status data from SSA life tables
Regression discontinuity analyses of disability and mortality by age
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America’s Uninsured Crisis: Consequences for Health and Health Care
Principal Findings*
Limitations
Having private insurance at baseline associated with significantly better health scores for a summary index of five general and physical health measures
No discernable impact of the introduction of Medicare in 1965 on overall mortality for elderly adults
Continuous insurance coverage associated with significantly fewer deaths among the near-elderly prior to age 65 (2.8% absolute decrease in death rate) and significant upward shift in distribution of general health states among those who survived (3.3% and 4.1% absolute increases in probability of excellent and very good health, respectively)
Validity of results depend on the validity of the instruments used; self-reported health outcomes
13% relative reduction in bed days and 5.1 percentage point decrease in 10-year mortality risk associated with Medicare eligibility after age 65
Effects not disaggregated by predictors of insurance status; comparisons by prior insurance status not possible with cross-sectional data; potentially spurious results due to data limitations of SSA life tables; formal testing of effects not consistently conducted; alternative explanations not addressed
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Study
Data
Methodological Approach
McWilliams et al. (2007)
Health of previously uninsured adults after acquiring Medicare coverage
Longitudinal survey data from the 1992-2004 HRS
Comparison of health trend changes at age 65 by prior insurance status
Pauly (2005)
Effects of insurance coverage on use of care and health outcomes for non-poor young women
Cross-sectional survey data from the 1996 MEPS
Instrumental variables analysis using firm size and marital status as instruments for health insurance status
Polsky et al. (2006)
The health effects of Medicare for the near-elderly uninsured
Longitudinal survey data from the 1992-2004 HRS
Comparison of health trend changes at age 65 by prior insurance status
Volpp et al. (2003)
Market reform in New Jersey and the effect on mortality from acute myocardial infarction
Cross-sectional state and national hospital discharge data from New Jersey, New York, and the NIS from 1990-1996
Difference-in-differences comparisons of mortality rates for hospitalized patients with acute myocardial infarction in New Jersey and New York before and after state reforms in New Jersey reduced subsidies for hospital care for the uninsured and introduced price competition
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America’s Uninsured Crisis: Consequences for Health and Health Care
Principal Findings*
Limitations
Medicare eligibility after age 65 associated with differentially improved health trends for previously uninsured with cardiovascular disease or diabetes in summary health (p = .006), change in general health (p = .03), mobility (p = .05), agility (p = .003), and adverse cardiovascular outcomes (p = 0.02); differential improvement also significant for depressive symptoms (p = .002) but not summary health (p = 0.17) for previously uninsured without these conditions
Self-reported health outcomes; subject to bias from differential mortality among previously uninsured or coincidental changes in time-varying predictors of health between comparison groups
Associations between insurance coverage and probability of fair or poor health not significant in either naïve or instrumental variables analyses
Validity of results depend on the validity of the instruments used; imprecise estimates; only one self-reported general health outcome assessed
Medicare eligibility after age 65 associated with significant improvements in health trajectories for both previously insured and previously uninsured adults; differential increase in probability of being in excellent or very good health after age 65 not significant for previously uninsured adults (+1.8%; 95% CI: −2.6,7.0
Only one self-reported general health outcome assessed; subject to bias from differential mortality among previously uninsured or coincidental changes in time-varying predictors of health between comparison groups
New Jersey health care reform associated with no significant changes in mortality for insured patients in New Jersey relative to New York or the nation, but with a significant differential increase of 3.7 to 5.2 percentage points in mortality rates for uninsured patients in New Jersey
Subject to bias from coincidental changes in state-specific predictors of mortality in insured and uninsured populations; mortality for only one conditions assessed; analysis limited to one state and may not generalize to national population of uninsured
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America’s Uninsured Crisis: Consequences for Health and Health Care
Study
Data
Methodological Approach
Volpp et al. (2005)
The effects of price competition and reduced subsidies for uncompensated care on hospital mortality
Cross-sectional state hospital discharge data from New Jersey and New York from 1990-1996
Difference-in-differences comparisons of mortality rates for hospitalized patients with 6 other acute conditions in New Jersey and New York before and after state reforms in New Jersey reduced subsidies for hospital care for the uninsured and introduced price competition
NOTE: HRS = Health and Retirement Study; MEPS = Medical Expenditure Panel Survey; NCHS = National Center for Health Statistics; NHIS = National Health Interview Survey; NIS = Nationwide Inpatient Sample; NPHS = National Population Health Survey; SEER = Surveillance, Epidemiology, and End Results; SSA = Social Security Administration.
*Point estimates, standard errors (se), 95% confidence intervals (CI), or P-values presented as reported in original articles.
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America’s Uninsured Crisis: Consequences for Health and Health Care
Principal Findings*
Limitations
New Jersey health care reform associated with relative increases in mortality for uninsured New Jersey patients with congestive heart failure (p < .05) and stroke (p > .05) compared to uninsured New York patients; mortality trends similar in New Jersey and New York for patients with other conditions, regardless of insurance status
Subject to bias from coincidental changes in state-specific predictors of mortality in insured and uninsured populations; analysis limited to one state and may not generalize to national population of uninsured
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