3
Coverage Matters

Abstract: If health insurance affects individuals’ health, functioning, and quality of life, it is by enabling access to effective health care services, including preventive services, early detection of disease, diagnostic services, treatment, rehabilitation, and palliative care. Important new research has emerged since the Institute of Medicine last studied the question of whether health insurance matters to health. This chapter draws from two commissioned systematic reviews of the evidence that was published from 2002 through August 2008 on the relationships between (1) health insurance coverage and access to potentially beneficial health care services, (2) access to potentially beneficial health care services and health outcomes, and (3) the overarching link between health insurance coverage and health outcomes. The committee concludes that the existing body of evidence is stronger and of higher quality than in the previous study. The committee further finds that, in the United States, health insurance coverage is integral to health care access and health. For people without health insurance, there is a chasm between health care needs and access to needed services despite the availability of some safety net services. With health insurance, children are more likely to gain access to a medical home, well-child care and immunizations, prescription medications, appropriate care for asthma, and basic dental services. They are also more likely to have fewer avoidable hospitalizations, improved asthma outcomes, and fewer missed days of school. Uninsured adults face serious and sometime grave risk to their health. Without health insurance, adults have less access to effective clinical services including preventive care and, if sick or injured, are more likely to suffer poorer heath outcomes, greater limitations in quality of life, and premature death. When adults gain health insurance, they experience improved access to effective clinical services and better health outcomes.



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3 Coverage Matters Abstract: If health insurance affects indiiduals’ health, functioning, and quality of life, it is by enabling access to effectie health care serices, in- cluding preentie serices, early detection of disease, diagnostic serices, treatment, rehabilitation, and palliatie care. Important new research has emerged since the Institute of Medicine last studied the question of whether health insurance matters to health. This chapter draws from two commissioned systematic reiews of the eidence that was published from 00 through August 00 on the relationships between () health insur- ance coerage and access to potentially beneficial health care serices, () access to potentially beneficial health care serices and health outcomes, and () the oerarching link between health insurance coerage and health outcomes. The committee concludes that the existing body of eidence is stronger and of higher quality than in the preious study. The committee further finds that, in the United States, health insurance coerage is inte- gral to health care access and health. For people without health insurance, there is a chasm between health care needs and access to needed serices despite the aailability of some safety net serices. With health insurance, children are more likely to gain access to a medical home, well-child care and immunizations, prescription medications, appropriate care for asthma, and basic dental serices. They are also more likely to hae fewer aoidable hospitalizations, improed asthma outcomes, and fewer missed days of school. Uninsured adults face serious and sometime grae risk to their health. Without health insurance, adults hae less access to effectie clinical serices including preentie care and, if sick or injured, are more likely to suffer poorer heath outcomes, greater limitations in quality of life, and premature death. When adults gain health insurance, they experience improed access to effectie clinical serices and better health outcomes. 

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0 AMERICA’S UNINSURED CRISIS When policy makers and researchers consider potential solutions to the problem of uninsurance in the United States, the question of whether health insurance matters to health is often an issue. This question is far more than an academic concern. It is crucial that U.S. health care policy be informed with current and valid evidence on the consequences of uninsurance for health care and health outcomes, especially for the 45.7 million individuals without health insurance. Some people might think it is obvious that not having health insurance will have adverse consequences for individuals’ health. On the other hand, some people believe that children and adults without health insurance have access to needed health care services at hospital emergency rooms, commu- nity health centers, or other safety net facilities offering charity care. And some observers note that there is a solid body of evidence showing that a substantial proportion of U.S. health care expenditures is directed to care that is not effective and may sometimes even be harmful. At least for the insured population, spending more and using more health care services does not always yield better health outcomes or increase life expectancy (Fisher et al., 2003; Fuchs, 2004; Wennberg and Wennberg, 2003; Wennberg et al., 2006). Is having health insurance essential for gaining access to appropriate health care services? Or is there evidence that the uninsured population receives the health care services necessary to achieve health outcomes com- parable to the insured population? This chapter provides a summary of the key findings from the research evidence on the relationships between health insurance and health outcomes that has emerged since the Institute of Medicine (IOM) released its last report on the issue in 2002 (IOM, 2002a). It is based on two systematic reviews of the literature on the consequences of uninsurance for individuals’ health outcomes commissioned by the com- mittee in 2008: one that evaluated the recent evidence pertaining to children and adolescents (Kenney and Howell, 2008) and a second that evaluated the evidence for adults (McWilliams, 2008).1 In 2002, the IOM judged the available evidence to be sufficiently strong and consistent to conclude that uninsured individuals do not receive needed health care services, and they suffer poorer health outcomes, including, for adults, greater risk of premature death (IOM, 2002a,b). Hadley drew simi- lar conclusions in a comprehensive and rigorous literature review conducted shortly thereafter (Hadley, 2003). Freeman and colleagues, who conducted 1The commissioned reviews of the research evidence from 2002 to August 2008 on conse- quences of uninsurance for access and health were (1) Health Consequences of Uninsurance Among Adults in the United States: An Update, by J. Michael McWilliams, M.D., Ph.D., Harvard Medical School; and (2) Health and Access Consequences of Uninsurance Among Children in the United States: An Update, by Genevieve M. Kenney, Ph.D., and Embry Howell, Ph.D., The Urban Institute. Much of the discussion in this chapter is based on these reviews.

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 COVERAGE MATTERS a more recent systematic review of the literature, reported in 2008 that the research consistently shows that health insurance increases the utiliza- tion of health care services and improves health outcomes (Freeman et al., 2008). Levy and Meltzer, on the other hand, have argued that the available evidence on the health effects of uninsurance on the general population is not convincing because of its reliance on observational research (Levy and Meltzer, 2008). These investigators do agree, however, that there is persua- sive evidence that health insurance improves the health outcomes of certain vulnerable subgroups, such as infants, children, and adults with AIDS. They also believe that there is evidence that health insurance improves blood pressure control and other specific measures of health for a broader popula- tion of adults, particularly low-income adults. CONCEPTuAL FRAMEWORk The focus of this chapter is on how health insurance affects children’s and adults’ health outcomes. One would expect that the greatest effects of not having health insurance would be on the health outcomes of individu- als who need health care the most, such as children with special health care needs and individuals who are acutely ill, suffer an injury or trauma, or have a chronic health condition. Of course, some health problems (e.g., obesity) may require a host of interventions beyond those provided through health insurance coverage (Forrest and Riley, 2004; Homer and Simpson, 2007). The conceptual framework and focus of the committee in examining the potential effects of uninsurance on individuals’ health outcomes is il- lustrated in Figure 3-1. If health insurance affects individuals’ health status, functional status, and quality of life, it is by enabling access to potentially beneficial health care—that is, by enabling the timely use of personal health services to achieve the best possible health outcomes (IOM, 1993). As shown in Figure 3-1, health insurance is one of several factors that enable access to care, others being financial resources, geographic location, lan- guage and culture, and transportation. Potentially beneficial health services include clinical preventive services, early detection of disease, diagnostic services, treatment, rehabilitation, and palliative care. Rehabilitative and palliative care services are not addressed in this report because the relevant research is extremely limited. Health insurance alone does not necessarily assure that individuals receive high-quality care (McGlynn et al., 2003). Other enabling factors, such as financial resources, geographic location, language and culture, and transportation, are also integral to health care access and outcomes, but are outside the scope of this study.

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 AMERICA’S UNINSURED CRISIS Potentially Beneficial Health Care Services Clinical preventive services (e.g., childhood Factors That Affect immunizations; adult cancer Potential Health Access to Health screening) Outcomes Care Early detection of disease Health status (morbidity Diagnosis and treatment for: Health insurance coverage and mortality) o Acute medical conditions Financial resources* Functional status (ability to (e.g., trauma, acute Geographic location* work, disability, childhood myocardial infarction) Language, culture* developmental milestones) o Chronic disease Transportation* Quality of life management (e.g., diabetes, asthma, hypertension) Rehabilitation* Palliative care* * Items shown in italics are not addressed in this report. FIguRE 3-1 Conceptual framework and focus of the chapter. *Items shown in italics are not addressed in this report. METHOD OF THE REvIEW As previously noted, this chapter is based on two systematic reviews of the research evidence on the consequences of uninsurance for individuals’ 3-1 new health outcomes that were commissioned by the committee in 2008: one review of the evidence pertaining to children and adolescents (Kenney and Howell, 2008) and a second review of the evidence for adults (McWilliams, 2008). The authors of these reviews conducted comprehensive searches for evidence pertaining to the three important relationships illustrated in Figure 3-1: (1) the link between health insurance coverage and access to potentially beneficial health care services, such as clinical preventive ser- vices, early detection of disease, diagnostic services, and treatment; (2) the link between access to potentially beneficial health care services and health outcomes, such as health status, functional status, and quality of life; and (3) the overarching link between health insurance coverage and potential health outcomes. Research Challenges in Assessing the Health Consequences of uninsurance What constitutes valid research evidence on the consequences of not having health insurance? Definitions of some key concepts that are impor-

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 COVERAGE MATTERS tant to interpreting the research evidence on the health consequences of uninsurance are provided in Box 3-1. Conclusions about the links between health insurance and health outcomes must be drawn with caution from observational studies that compare health-related outcomes of insured and uninsured adults and use statistical techniques to adjust for differences in other predictors of health that may be related to health insurance status. Assessing the effect of uninsurance on health outcomes is a research chal- lenge for two main reasons. First, insured and uninsured adults may differ greatly in demographic or socioeconomic characteristics, environmental influences, clinical risk fac- tors, health behaviors, preferences, or other predictors of health. It is virtu- ally impossible to measure all systematic differences between these groups, some of which may be unobservable, let alone measure them all with preci- sion. Moreover, most comparisons of insured and uninsured adults rely on previously collected data on a limited set of variables. As a result, important differences may remain after statistical adjustments that explain observed differences in health between insured and uninsured adults. Second, not only might health insurance status affect health, but health may also affect health insurance status. Health declines, for example, lead to coverage gains through increased demand for private insurance or eligi- bility for public insurance, or lead to uninsurance through job loss, income reductions, or selection behaviors on the part of insurers. Thus, cross-sec- tional associations between health insurance status and health may be due to the effects of health on health insurance rather than the reverse. Because of the limitations of observational comparisons, conclusions about the health consequences of uninsurance would ideally rely on experi- mental or quasi-experimental evidence (Levy and Meltzer, 2008). Without random assignment of insurance status, estimated effects cannot be char- acterized as causal with absolute certainty. The RAND Health Insurance Experiment, however, remains the only large experimental study of health insurance in which features of coverage were randomly assigned, and ethi- cal and practical considerations make future trials of its kind unlikely. Fur- thermore, the RAND Health Insurance Experiment was conducted many years ago and did not include an uninsured group, thus its findings may not generalize to the current population of uninsured adults. Given the limitations of observational studies and the dearth of experi- mental studies of the effects of health insurance, findings from quasi-experi- mental studies should be given greatest weight in formulating conclusions about the consequences of uninsurance (Levy and Meltzer, 2008). Still, the merits of observational studies should not be ignored. The results of quasi-experimental studies often cannot be generalized beyond a local or marginal group affected by a specific policy, and larger observational stud- ies may support inferences about broader populations, particularly when

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 AMERICA’S UNINSURED CRISIS BOX 3-1 Key Concepts in Assessing Evidence on the Health Consequences of Uninsurance Endogenous variable. The dependent outcome variable in a study of cause and effect (e.g., mortality rates in studies of the impact of health insurance on mortality). Exogenous variable. The independent explanatory variable in a study of cause and effect (e.g., health insurance coverage in a study of the effect of health insur- ance on mortality). The possibility that an endogenous variable, such as health insurance status, may be in fact endogenous, poses a challenge in determining cause and effect. Thus, for example, sicker people may be less likely to have health insurance because they are not working, in which case the lack of health insurance is due to poor health rather than the reverse. Experimental study. A study in which the investigators actively intervene to test a hypothesis. In a randomized controlled trial of a drug, for example, participants are randomly assigned by the investigators to either the treatment group (which receives the drug) or the control group (which does not receive the drug). Such study designs can be used to draw firm conclusions about the effects of health insurance on health outcomes. The RAND Health Insurance study is an example, but ethical and practical considerations make future experimental studies on the effects of health insurance unlikely. Natural experiment. A type of quasi-experimental study in which the circum- stances in which different populations are exposed or not exposed to an inter- vention resemble those in an experimental study (in which study participants are randomly assigned to exposed and unexposed groups). Policy changes that expand eligibility for health insurance coverage to some people but leave a rela- tively similar group uncovered, such as the enactment of Medicare or the State findings are consistent across observational and quasi-experimental analy- ses of similar outcomes. Observational analyses of detailed data may also allow testing of hypothesized confounders, and sensitivity analyses can be used to characterize the robustness of estimated associations. In this way, potentially causal pathways may be explored, paving the way for more definitive work. For certain outcomes or populations, strong quasi-experimental designs may not be readily available, leaving observational evidence, albeit limited, as the sole source of information for policy makers. For example, although the research evidence on the health effects of health insurance is stronger and of higher quality than ever before, there are marked differences in the nature of the evidence for children and adults. As will be described later in the chapter, the research on children draws on strong, well-designed

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 COVERAGE MATTERS Children’s Health Insurance Program (SCHIP), can provide a natural experiment for assessing the effects of health insurance on health outcomes. Observational study. A study in which investigators simply observe the course of events. Examples are cohort and cross-sectional studies. In cohort studies, groups with certain exposures or characteristics (e.g., no health insurance) are monitored over time to observe an outcome of interest (e.g., the quality of dia- betes management over time). In cross-sectional studies, the prevalence of an outcome of interest (e.g., mortality among heart attack victims) is measured at a specific time or time period. Such observational studies are less definitive than experimental or quasi-experimental studies of the effects of health insurance on health outcomes. Quasi-experimental study. A study in which empirical methods (e.g., difference- in-differences, interrupted time series, regression discontinuity, and instrumental variables methods) are applied to address the endogeneity of health insurance and health (i.e., bias from unmeasured confounding or reverse causality) by identifying the health effects of coverage changes or coverage differences that are possibly exogenous, or unrelated to health, and all observed or unobserved predictors of both coverage and health. In essence, quasi-experimental designs attempt to balance unobserved variables in studies using observational data. Sensitivity analysis. An analysis of how “sensitive” a model is to changes to dif- ferent sources of variation in the factors including in the model. Study quality. For an individual study, study quality refers to all aspects of a study’s design and execution including the extent to which bias is avoided or minimized. SOURCES: IOM (2008); Levy and Meltzer (2008). evaluations of children’s participation in SCHIP, Medicaid, or county-based health insurance initiatives. These studies typically measure impacts on access to care and use basic statistical models to assess observational data and to control for confounding variables. Most of the research on children does not employ more sophisticated quasi-experimental techniques to bal- ance unobserved characteristics between insured and uninsured groups in observational data. There are, however, several notable quasi-experimental studies of children that assess the health effects of coverage including asthma outcomes, timely diagnosis of serious conditions, and unnecessary hospitalizations (see later section on children’s health outcomes for further details). In contrast, as this chapter will show, recent research has produced a robust quasi-experimental body of evidence on the effects of lacking in- surance and gaining insurance on adult health.

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 AMERICA’S UNINSURED CRISIS Literature Search Strategy As noted earlier, the committee commissioned systematic reviews of literature, published since 2002, on the health consequences of uninsur- ance for children and for adults in the United States. This section describes the search strategies for the two reviews. Box 3-2 provides the search terms used to identify the relevant literature. The searches were supple- mented with known, relevant reports not identified through the electronic databases. BOX 3-2 Literature Search Strategy Systematic searches of the National Library of Medicine’s MEDLINE and the American Economic Association’s EconLit databases were conducted to identify potentially relevant studies published since 2002. Three Medical Subject Heading Terms from the National Library of Medicine’s controlled vocabulary, “medically uninsured,” “medical indigency,” and “uncompensated care,” were used to search MEDLINE. The searches in the EconLit database used keywords from a prior literature review and included “health insurance” or “payer source” in combination with the terms “asthma,” “diabetes,” and “obesity” for children, and “health status,” “health outcomes,” “mortality,” “hypertension,” “heart disease,” “diabetes,” “stroke,” “cancer,” “HIV,” or “depression” for adults (Hadley, 2003). Literature on Consequences for Children The children’s literature search was conducted in June 2008. It was limited to children ages 0 to 18 years. In addition to the searches described above, a supple- mentary MEDLINE search on children was conducted using the Medical Subject Heading term “insurance, health” and then limited further with several narrow terms, including “accidents,” “adolescent,” “ambulatory care,” “asthma,” “cancer,” “dental care/dental caries,” “diabetes,” “emergency service, hospital,” “immuniza- tion,” “mental disorders,” “mental health,” “preventive health services,” “SCHIP,” “special health care needs,” “wounds and injuries,” and “medically uninsured.” In total, the search of the children’s literature generated 1,233 (MEDLINE) and 25 (Econlit) citations which were then screened for inclusion. Citations from selected author searches and bibliographies of more recent reviews were also screened. Literature on Consequences for Adults The adult search was conducted in August 2008. It was limited to studies that included adults ages 19 and older. In total, the search of the adult literature generated 755 (MEDLINE) and 192 (Econlit) citations which were then screened for inclusion. Citations from selected author searches and bibliographies of more recent reviews were also screened (Freeman et al., 2008; Levy and Meltzer, 2004, 2008).

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 COVERAGE MATTERS Literature on the Effects of Uninsurance on Children Studies on children were identified through systematic searches of the National Library of Medicine’s MEDLINE and the American Economic Association’s EconLit databases. The evidence base for establishing how and under what circumstances health insurance affects the health and functioning of children remains limited. The literature search identified many more studies examining the effects on children’s access to care and service use than on their health status or functioning. Studies on children were included in this review if they estimated the effects of health insur- ance coverage on validated access measures (i.e., having a usual source of care, having a preventive visit or any ambulatory care visit, having unmet health needs, receiving recommended immunizations, having a usual source for dental care, having received a preventive dental visit or any dental care, and having an unmet need for dental care) or health outcomes. Ultimately, 57 studies on children were selected for inclusion in this review. Literature on the Effects of Uninsurance on Adults Studies on adults were similarly identified through systematic searches of the National Library of Medicine’s MEDLINE database and the Ameri- can Economic Association’s EconLit database. A key requisite for inclusion in the review was the demonstration of a distinct contribution to the re- search reviewed in the IOM’s previous report (IOM, 2002a). Potential con- tributions were considered in each of the following dimensions: (1) strength of study design and methodological rigor (e.g., quasi-experimental vs. observational design, inclusion of sensitivity analyses, handling of missing data); (2) quality of the data (e.g., longitudinal vs. cross-sectional, level of clinical detail, unique linkages); (3) importance of outcomes (e.g., validated measures of health vs. processes of care); and (4) external validity of results (e.g., findings generalizable to broader populations or previously unstudied diseases). Observational studies were excluded from the review unless they compared health outcomes for insured and uninsured adult subjects and investigated the sensitivity of results to statistical adjustments for observed demographic and socioeconomic characteristics. Ultimately, 42 studies on adults were selected for inclusion in this review. FINDINgS The results of the literature searches are summarized in this section. This new body of evidence on the beneficial consequences of health insur- ance and the harms of uninsurance is stronger than ever before. Health

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 AMERICA’S UNINSURED CRISIS insurance coverage matters. Children and adults without health insurance have less access to beneficial health care services and poorer health out- comes than those who have health insurance. Five tables summarizing the findings of recent studies on the impact of health insurance on children’s access to and use of general health care services; children’s access to and use of dental services, children’s immu- nizations; children with special health care needs, and children’s health status and related outcomes are presented in Appendix D. A single table that summarizes the findings of quasi-experimental studies of the effects of health insurance coverage on health outcomes for adults is presented in Appendix E. Effects of Health Insurance on Access to Health Care Services The new evidence on the effects of health insurance on children’s and adult’s access to health care services is summarized below. As detailed fur- ther below, there is solid evidence that health insurance improves children’s access to beneficial preventive care and other effective health services. Children who obtain health insurance are more likely to gain access to a usual source of care or medical home, well-child care and immunizations to prevent illness and monitor developmental milestones, prescription medi- cations, appropriate care for asthma, and basic dental services. Uninsured children with special health needs are much less likely to have access to specialists than their insured peers. For adults, new evidence consistently and robustly demonstrates a wide range of positive effects of health insurance coverage on the receipt of ben- eficial preventive and other health care services. Without health insurance, adults have less access to effective clinical services including preventive care and, if sick or injured, are more likely to suffer poorer heath outcomes, greater limitations in quality of life, and premature death. When adults gain health insurance, they experience improved access to effective clinical ser- vices and better health outcomes. In sum, the best evidence that is available establishes important mediating links in the pathway from health insurance to health outcomes and suggests substantial potential for beneficial effects on adult health. Effects on Children’s Access to Health Care Serices Finding: Children benefit considerably from health insurance, as dem- onstrated by evaluations of enrollment in Medicaid and the State Chil- dren’s Health Insurance Program (SCHIP).

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 COVERAGE MATTERS Finding: When children acquire health insurance, their access to health care services, including ambulatory care, preventive health care (e.g., immunizations), prescription medications, and dental care, improves. Finding: When children acquire health insurance, they are much less likely to experience unmet health care needs, both when they are well or when they have special health care needs. Although children in the United States are typically perceived as in good health relative to adults, certain conditions including asthma, diabe- tes, and obesity have become relatively common among children. Further, there is a population of particularly vulnerable children with special health care needs that require ongoing medical attention and other health-related services. More than 10 million children in the United States meet the fed- eral definition of children with special health care needs—i.e., children “who have or are at increased risk for a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” (American Academy of Pediatrics, 2008). Such children with conditions such as asthma, arthritis or other joint problems, autism, blood problems, Down syndrome, mental retardation/developmental delays, depression, dia- betes, heart problems, cystic fibrosis, cerebral palsy, or muscular dystrophy require health and related services of a type or amount beyond that required by children generally. Research linking health insurance and children’s access to care has flourished since the IOM’s last study, particularly regarding the potential benefits of enrolling in a publicly sponsored health insurance program. New evidence from well-designed studies draws on state-level expansions of the SCHIP and Medicaid programs in 14 states and for local programs in three different California counties. The 14 states—California, Colo- rado, Florida, Illinois, Iowa, Kansas, Louisiana, Massachusetts, Missouri, North Carolina, New Jersey, New York, Tennessee, and Texas—account for over 60 percent of the nation’s low-income children, represent all four census regions and major SCHIP program types, and vary with respect to program size and composition (Kenney, 2007). The new evidence, discussed further below, strongly supports the find- ing that expansions in eligibility for Medicaid and SCHIP have produced gains in access to medical care for children targeted by the eligibility ex- pansions, as well as the finding that positive spillover effects may arise for children who were already eligible for coverage. Well-designed evaluations of children’s participation in SCHIP, Medicaid, or county-based initiatives have generated consistent and robust evidence showing that children’s ac-

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0 AMERICA’S UNINSURED CRISIS sis of mortality rates identified an abrupt decrease of 1 percentage point in 7-day mortality at age 65, suggesting that Medicare coverage reduced the overall death rate for these acutely ill patients by 20 percent. The mortal- ity effect persisted for at least 2 years after admission, suggesting a lasting impact of increased use of beneficial procedures and medications. The decline in mortality was too large to be explained by changes in cross-sec- tional rates of uninsurance from age 64 to 65, suggesting that near-elderly adults who have limited public or private coverage may also benefit from Medicare coverage. Doyle conducted an observational study of adults injured in severe automobile accidents in Wisconsin (Doyle, 2005). By focusing on seriously injured drivers who were unable to participate in their initial treatment decisions, this analysis successfully addressed any differences in care-seek- ing behaviors between insured and uninsured adults that might bias the findings. The study found that, compared to privately insured patients, the uninsured crash victims received 20 percent less care (i.e., especially more costly procedures and services) and had a substantially higher mortality rate—an increase of 1.5 percentage points above the mean rate of 3.8 per- cent. The study controlled for an array of potentially confounding factors and included sensitivity analyses to test the robustness of the results. These studies of hospitalized patients suggest that health insurance coverage may not only affect patients’ demand for health care services, but also provider behaviors in delivering care. Therefore, coverage expansion may not only improve outcomes for acutely ill patients by reducing delays before needed care, but also by allowing providers to offer effective but costly procedures and treatments at more equitable rates. In another observational study, Hadley assessed insured and unin- sured adults medical care and health status after unintentional injuries or newly diagnosed chronic conditions (Hadley, 2007). Using data from MEPS during 1997 to 2004, he found that, compared with insured adults, the uninsured adults received significantly fewer health care services, were less likely to fully recover, and more likely to report subsequent declines in health status. Higher Mortality Rates Overall. Prior to 2002, two observational studies provided evidence that uninsured adults die at younger ages than their privately insured counterparts (IOM, 2002a). Of these two studies, the analysis that adjusted for more demographic, socioeconomic, and health characteristics estimated that the relative risk of death over 13 to 17 years was 25 percent greater for adults who were uninsured at baseline than for adults who were privately insured (Franks et al., 1993). Two subsequent observational analyses of data from the HRS estimated this increased rela- tive risk to be 35 percent to 43 percent for uninsured near-elderly adults

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 COVERAGE MATTERS after controlling for even more predictors of mortality (Baker et al., 2006a; McWilliams et al., 2004). The association between uninsurance at baseline and subsequently higher mortality risk was particularly strong among near- elderly adults who were white, had low incomes, or had diabetes, hyper- tension, or heart disease (McWilliams et al., 2004). A sensitivity analysis demonstrated that the explanatory effect of an unmeasured predictor would have to be greater than the impact of smoking on mortality differences between insured and uninsured adults in the study for the increased risk among the uninsured to lose statistical significance. Another related study also found lack of health insurance was associated with major health de- clines, but not an increased risk of death within 2 years, suggesting that pre- mature death is likely to be a long-term rather than short-term consequence of uninsurance among near-elderly adults (Baker et al., 2006b). Because mortality generally represents a longer-term outcome for all but the severely or acutely ill, quasi-experimental analyses designed to identify abrupt discontinuities in mortality rates or even linear trends in mortality may not be suitable for estimating the effects of health insur- ance on mortality in the general population. Lichtenberg used life tables produced by the Social Security Administration and found a dramatic drop in the growth rate in annual probabilities of death for adults beginning at age 65 (Lichtenberg, 2002). However, in a subsequent analysis of National Center for Health Statistics Multiple Cause of Death files, Card and col- leagues found no evidence of a deceleration in mortality rates at age 65 (Card et al., 2004). Similar assessments of the introduction of Medicare in 1965 found no discernable impact on mortality for beneficiaries (Card et al., 2004; Finkelstein and McKnight, 2005), although many subsequent medical advances have improved the effectiveness of health care for elderly adults in the United States. Because of the often delayed effects of health services on survival, these null findings from some types of quasi-experimental studies should be in- terpreted with caution and are not necessarily inconsistent with positive findings from the observational comparisons described above. Indeed, in an instrumental variables analysis of longitudinal data, Hadley and Waidmann estimated that with universal health coverage, the absolute death rate for nonelderly adults could decrease from 6.7 percent to 3.9 percent (Hadley and Waidmann, 2006). CONCLuSION Important new research has emerged since the IOM last studied the question of what is known about the health consequences of health insur- ance for children and adults in 2002 (IOM, 2002a,b). These new findings convincingly suggest substantial health benefits of health insurance cover-

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 AMERICA’S UNINSURED CRISIS BOX 3-5 Summary of the Evidence on the Health Effects of Uninsurance for Children and Adults Children benefit considerably from health insurance, as demonstrated by recent evaluations of enrollment in Medicaid and the SCHIP program: • When previously uninsured children acquire insurance, their access to health care services, including ambulatory care, preventive health care (e.g., immunizations), prescription medications, and dental care improves. • When previously uninsured children who are well or have special health needs acquire insurance, they are less likely to experience unmet health care needs. Uninsured children with special health care needs are much more likely to have an unmet health need than their counterparts with insurance. • When previously uninsured children acquire insurance, they receive more timely diagnosis of serious health conditions, experience fewer avoidable hospitalizations, have improved asthma outcomes, and miss fewer days of school. Adults benefit substantially from health insurance for preventive care when they are well and for early diagnosis and treatment when they are sick or injured: • Without health insurance, men and women are less likely to receive effec- tive clinical preventive services. • Without health insurance, chronically ill adults are much more likely to delay or forgo needed health care and medications. • Without health insurance, adults with cardiovascular disease or cardiac risk factors are less likely to be aware of their conditions, their conditions are less likely to be well controlled, and they experience worse health outcomes. • Without health insurance, adults are more likely to be diagnosed with later- stage breast, colorectal, or other cancers that are detectable by screening or symptom assessment by a clinician. As a consequence, when uninsured adults are diagnosed with such cancers, they are more likely to die or suffer poorer health outcomes. • Without health insurance, adults with serious conditions, such as cardio- vascular disease or trauma, have higher mortality. • The benefits of health insurance have been clearly demonstrated through recent studies of the experiences of previously uninsured adults after they acquire Medicare coverage at age 65. These studies demonstrate when previously uninsured adults gain Medicare coverage: o Their access to physician services and hospital care, particularly for adults with cardiovascular disease or diabetes, improves. o Their use of effective clinical preventive services increases. o They experience substantially improved trends in health and functional status. o Their risk of death when hospitalized for serious conditions declines.

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 COVERAGE MATTERS age. Important insights into how children benefit when they acquire health insurance are provided by well-designed evaluations of enrollment in Med- icaid and the SCHIP program. And compelling findings on how adults are harmed by the lack of health insurance are available from new longitudinal analyses of previously uninsured adults after they acquire Medicare cover- age at age 65 and other research. The findings from the research described in this chapter are summarized in Box 3-5. With health insurance, it is clear that children are more likely to gain access to a usual source of care or medical home, well-child care and immunizations to prevent future illness and monitor developmental mile- stones, prescription medications, appropriate care for asthma, and basic dental services. With health insurance, serious childhood health problems are more likely to be identified early and children with special health care needs are more likely to have access to specialists. With health insurance, children have fewer avoidable hospitalization, improved asthma outcomes, and fewer missed days of school. Without health insurance, several deleterious patterns emerge for adults. Men and women are much less likely to receive clinical preventive services that have the potential to reduce unnecessary morbidity and prema- ture death. Chronically ill adults delay or forgo visits with physicians and clinically effective therapies, including prescription medications. Adults are more likely to be diagnosed with later-stage cancers that are detectable by screening or by contact with a clinician who can assess worrisome symp- toms. Without health insurance, adults are more likely to die from trauma or other serious acute conditions, such as heart attacks or strokes. Adults with cancer, cardiovascular disease (including hypertension, coronary heart disease, and congestive heart failure), stroke, respiratory failure, COPD or asthma exacerbation, hip fracture, seizures, and serious injury are more likely to suffer poorer heath outcomes, greater limitations in quality of life, and premature death. New evidence demonstrates that gaining health insur- ance ameliorates many of these deleterious effects, particularly for adults who are acutely or chronically ill. In sum, despite the availability of some safety net services, there is a chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless ill- ness, suffering, and even death. Health insurance coverage in the United States is integral to personal well-being and health. REFERENCES AHRQ Center for Financing Access and Cost Trends. 2008 (unpublished). Tabulations from the 00 Medical Expenditure Panel Surey (commissioned by the IOM Committee on Health Insurance Status and Its Consequences).

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