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HEALTH CARE POLICY Uninsured Adults Not Receiving Needed CareGoing Without Health Insurance Shown to Be Serious Health Risk National surveys reflect a growing perception that uninsured Americans can get proper health care through various "safety net" facilities. Not true, says a study led by HMS researchers in the Oct. 25 JAMA, which revealed high proportions of long-term uninsured adults in poor or fair health who are not getting needed care.
A large gap in the U.S. health care safety net is reflected by the nearly 70 percent of long-term uninsured people in poor health who went without needed care in the previous year because it was too expensive. "Many uninsured adults are going without proper medical attention," said the study's lead author, John Ayanian, HMS associate professor of health care policy and of medicine at Brigham and Women's Hospital. "Thirty-two percent of women without health insurance for over a year report not getting a mammogram in the past two years. Twenty-six percent of the long-term uninsured with hypertension or diabetes say they haven't had a check-up with a doctor in two years. From a public health perspective, these numbers are very concerning." According to the study, which examined 1997–98 survey data for more than 220,000 adults aged 18 to 64 from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, 14 percent lacked health insurance, and nearly 10 percent had gone without health insurance for at least a year. These percentages are representative of the approximately 163 million U.S. adults living in households with telephones. Quiet CrisisThirty-nine percent of the long-term uninsured adults (those without health insurance at least a year) and 30 percent of the short-term uninsured, reported not being able to see a physician when needed in the past year due to cost. Cost barriers to seeing a physician among uninsured adults were greatest for women, blacks, the unemployed, and those with low incomes.The numbers were worse for those not in good health. Nearly 70 percent of long-term uninsured adults who also reported being in poor health, and nearly 50 percent who reported being in fair health, said they could not see a physician when needed in the past year due to cost, as compared with 52 percent and 42 percent of short-term uninsured adults, and 22 percent and 16 percent of insured adults. "Long-term uninsured adults, particularly those in poor health or with chronic medical conditions, are a high-risk group for complications and early death, and many of these adults are not receiving the medical care they need," Ayanian said. "Studies such as this one prove that living without insurance is a serious health risk that needs to be treated with the same sense of urgency as not wearing seatbelts or drunk driving," said Sandra Adamson Fryhofer, president of the American College of Physicians–American Society of Internal Medicine, which funded the study. "This evidence proves that preventive care is crucial to the health and well-being of the patient. Unfortunately, those without insurance often cannot get treatment for diseases such as diabetes, and consequently undergo unnecessary hospitalizations and more costly treatments." Compounding this public health dilemma, smokers and binge drinkers were uninsured more often than adults without these risk factors. Further, for highly recommended preventive services, long-term uninsured adults were significantly less likely to receive mammography screening or Pap smears, hypertension and cholesterol testing, or colon cancer screening. Short-term uninsured adults had intermediate rates of unmet needs for preventive services that were statistically higher than the rates of insured adults for mammography, Pap smears, and hypertension and cholesterol screening. These findings, according to the study's authors, challenge the views expressed in national surveys that show a growing proportion of Americans—from 43 percent in 1993 to 57 percent in 1999—believe uninsured people are able to get the care they need from physicians and hospitals. The Cost of Insufficient CareThe authors assert that failing to monitor or effectively treat chronic illnesses such as hypertension or diabetes in uninsured adults can result in substantial morbidity and may increase the nation's health care costs. The more expensive medical care used to treat preventable complications of chronic illnesses are absorbed by providers as free care, passed on to private insurers through cost shifting and higher fees, or paid through higher taxes to finance public hospitals and public insurance programs.This study includes adults from all 50 states and the District of Columbia who completed the 1997 and 1998 Behavioral Risk Factor Surveillance System survey, including 105,764 respondents in 1997 and 117,634 in 1998. Adults older than 64 were ex-cluded because almost all are eligible for Medicare insurance. In addition to Ayanian, the study's co-authors were Joel Weissman, HMS assistant professor of medicine at Massachusetts General Hospital; Eric Schneider, HSPH instructor in health policy and management and HMS instructor in medicine at Brigham and Women's Hospital; Jack Ginsburg, American College of Physicians–American Society of Internal Medicine; and Alan Zaslavsky, HMS associate professor of statistics. —John Lacey |
