Coverage Matters for Individuals

Public opinion on this question has shifted overtime; but in 1993, when health care was at the top of the national political agenda, fully 43 percent of Americans agreed with the statement that uninsured people are "able to get the care they need from doctors and hospitals."¹ And just 7 years ago, in 1999, a majority (57 percent) of Americans held this view. Clearly, there is a commonly held belief in this country that uninsured Americans get the health care they need.² However, available evidence shows that this belief is clearly false.

Adults

In their landmark study of the consequences of uninsurance,³ the Institute of Medicine concluded that "adults without coverage do not get the care they need and are more likely to suffer poor health and premature death than are insured adults." A more recent study also found that the uninsured receive less care than the insured and experience poorer outcomes.⁴

Long-term studies indicate that, compared to insured adults, uninsured adults have a 25 percent greater risk of premature death. This mortality difference exists after social, demographic, health status and health behavior differences are statistically removed.⁵
The Institute of Medicine estimates that the number of excess deaths each year among uninsured adults, age 25-64, is 18,000.⁶ By way of comparison, consider the number of estimated annual deaths in the under age 65 population due to the following causes:
- Diabetes: 17,500
- Stroke: 19,000
- HIV/AIDS: 14,100
- Homicide 19,700⁷

Preventive Care

Uninsured adults are less likely to receive recommended preventive and screening services than insured adults. This includes:
- Pap tests for cervical cancer in women,
- Clinical breast exams and mammography in women,
- Fecal occult blood tests for colorectal cancer,
- Sigmoidoscopies for colorectal cancer,
- Blood pressure checks for hypertension, and
- Cholesterol tests.⁸
Compared to adults with insurance, when uninsured adults receive screening services, they are less likely to receive them on a timely basis.⁹
Because they lack timely access to screening services, uninsured adults with cancer (breast, colon, prostate) tend to have poorer outcomes and are more likely to die prematurely than adult cancer patients with insurance. Poor access to screening services results in delayed diagnosis; and survival probability is a function of the stage of the cancer at diagnosis.¹⁰
The longer adults under age 65 are without health insurance, the less likely they are to receive preventive services.¹¹
Health insurance coverage increases access to and use of preventive services, but it does not erase disparities in the use of these services among racial groups.¹²

Chronic Care

Chronic conditions—including cardiovascular disease, diabetes, terminal kidney disease, HIV infection, and mental illness—are the leading cause of death, disability, and illness in the United States.¹³

Uninsured adults with cardiovascular disease receive fewer professionally recommended services and experience worse health outcomes than insured adults with cardiovascular disease. They are less likely to:
- be screened for hypertension and high cholesterol,¹⁴
- have their blood pressure monitored frequently,¹⁵ and
- stay on drug therapy for hypertension.¹⁶
Diabetes requires intensive care management, but non-elderly adult diabetics are almost as likely to be uninsured as non-elderly adults in general.¹⁷
- Compared to insured non-elderly adults with diabetes, uninsured diabetics are less likely to receive appropriate standards of care, which can lead to uncontrolled blood sugar levels, greater risk of hospitalization, and increased risk of additional chronic disease and disability.¹⁸
- Among non-elderly adult diabetics, lack of insurance is associated with less glucose monitoring and fewer foot and eye exams. These services are professionally recommended disease management strategies.¹⁹
Compared to insured non-elderly adults, those without insurance
- who have end-stage renal disease are more likely to begin dialysis once the disease has progressed to a more advanced stage, which has a negative effect on health outcomes.²⁰
- who have HIV infection are less likely to receive the most effective drugs, are more likely to fail to receive needed care²¹ , and have a higher risk of mortality.²²
Compared to insured adults with behavioral health coverage, uninsured adults are less likely to receive mental health services consistent with recommended treatment guidelines.²³ Uninsured adults with severe mental illness are much less likely to use specialty mental health services than publicly insured persons. ²⁴

Pregnant Women and Children

After conducting an exhaustive review of the literature, the Institute of Medicine concluded that "[h]aving health insurance increases the chances that infants, children, and pregnant women will receive preventive services when well, and timely medical care when sick or at high risk of poor outcomes. These, in turn, help avoid unnecessary hospitalizations, premature births, extended morbidity, or even death."²⁵

The IOM was careful to note, however, that "[a]lthough having insurance makes a difference, simply making insurance available may not be enough to improve health care and health outcomes for all of the uninsured. Some high-risk groups may require additional services (e.g., educational interventions, targeted case management) if they are to obtain good preventive and routine care."²⁶

Pregnant Women

Uninsured pregnant women use fewer prenatal services than publicly or privately insured pregnant women. In one study, the rate of unmet needs reported by uninsured women (18 percent) was more than twice that of insured women.²⁷
Pregnant women without health insurance are less likely to receive expensive maternity and neonatal services. For example, the caesarian section rate for uninsured women is lower than the rate for insured women. Although it is believed by some that c-section is an overused procedure, a study that examined insurance status differences in c-section rates when it was an appropriate procedure (in cases of breech presentation or fetal distress) found lower use rates among uninsured women.²⁸

Medicaid expansions during the late 1980s brought public coverage to many previously uninsured women. Although the evidence is mixed, some studies show significant population-level changes in the use of prenatal services following Medicaid expansion.²⁹

Children

Uninsured children have less access to health care providers and use health services less frequently than children with private or public insurance.³⁰
When previously uninsured children are enrolled in public insurance programs, they use more health services and use health services more appropriately.³¹
Multiple factors hinder children's access to, and use of, health services, including low income, immigrant status, and certain race/ethnicity categories. Because 40 percent of children in one of these groups are in at least one other, the barriers to health care access and use are compounded for many children.³²
Although having insurance coverage improves access to and use of care for children, other important factors include "poverty, diet, exercise, smoking, and other behavioral factors."³³

Sources

¹Blendon et al., 1999, p. 207 (IOM, p 21, bottom)

²Institute of Medicine (IOM). 2001. Coverage Matters. Insurance and Health Care. Washington, DC: National Academy Press, p. 21.

³Institute of Medicine (IOM). 2001. Coverage Matters. Insurance and Health Care. Washington, DC: National Academy Press; Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press; Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press; Institute of Medicine (IOM). 2003. A Shared Destiny. Community Effects of Uninsurance. Washington, DC: National Academy Press; Institute of Medicine (IOM). 2003. Hidden Costs, Value Lost. Uninsurance in America. Washington, DC: National Academy Press

⁴Hadley, Jack, 2007. "Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition," Journal of the American Medical Association 297:1073-1084.5Franks, Peter; Carolyn Clancy, and Marthe Gold. 1993. Health Insurance and Mortality. Evidence from a National Cohort. Journal of the American Medical Association 27(6):737-741.

⁵Franks, Peter; Carolyn Clancy, and Marthe Gold. 1993. Health Insurance and Mortality. Evidence from a National Cohort. Journal of the American Medical Association 27(6):737-741.

⁶Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press pp. 161-165 and Table D.1.

⁷Institute of Medicine (IOM). 2004. Insuring America's Health. The National Academies Press, Washington, D.C., p. 46.

⁸For multiple sources, see Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press, pp. 47-51.

⁹Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press, p. 48.

¹⁰Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press, pp. 52-57.

¹¹Ayanian, John, Joel Weissman, Eric Schneider, Jack Ginsburg, et al. 2000. Unmet Health Needs of Uninsured Adults in the United States. Journal of the American Medical Association 284(16):2061-2069.

¹²Has, Jennifer and Nancy Adler. 2001. The Causes of Vulnerability: Disentangling the Effects of Race, Socioeconomic Status and Insurance Coverage on Health. Background paper prepared for the Committee on the Consequences of Uninsurance.

¹³Centers for Disease Control and Prevention (CDC). 2000. "Chronic Disease Prevention: Heart Disease and Health Promotion." Web page, not accessible on April 13, 2004, but see other performance plans at www.cdc.gov/od/perfplan/ [1]

¹⁴Ayanian, John, Joel Weissman, Eric Schneider, Jack Ginsburg, et al. 2000. Unmet Health Needs of Uninsured Adults in the United States. Journal of the American Medical Association 284(16):2061-2069.

¹⁵Fish-Parcham, Cheryl. 2001. Getting Less Care: The Uninsured with Chronic Health Conditions. Washington, DC: Families USA Foundation.

¹⁶Huttin, Christine, John Moeller, and Randall Stafford. 2000. Patterns and Costs for Hypertension Treatment in the United States. Clinical Drug Investigation 20(3):181-195; Fish-Parcham, Cheryl. 2001. Getting Less Care: The Uninsured with Chronic Health Conditions. Washington, DC: Families USA Foundation.2001

¹⁷Harris, Maureen. 1999. Racial and Ethnic Differences in Health Insurance Coverage for Adults with Diabetes. Diabetes Care 22(10):1679-1682.

¹⁸Palta, Mari, Tamara LeCaire, Kathleen Daniels, Guanghong Shen, et al. 1997. Risk Factors for Hospitalization in a Cohort with Type 1 Diabetes. American Journal of Epidemiology 146(8):627-636.

¹⁹Beckles, Gloria, Michael Engelgau, KM Venkat Narayan, William Herman, et al 1998. Population-Based Assessment of the Level of Care Among Adults with Diabetes in the U.S. Diabetes Care 21(9):1432-1438.

²⁰Obrador, Gregorio, Robin Ruthazer, Arora Pradeep, Annamaria Kausz, et al. 1999. Prevalence of and Factors Associated with Suboptimal Care Before Initiation of Dialysis in the United States. Journal of the American Society of Nephrology 10(8):1793-1800.; Kausz, Annamaria T., Gregorio T. Obrador, Pradeep Arora, Robin Ruthazer, et al. 2000. Late Initiation Dialysis Among Women and Ethnic Minorities in the United States. Journal of the American Society of Nephrology 11(12):2351-2357.

²¹Cunningham, William E., Ron D. Hays, Kevin W. Williams, Keith C. Beck, et al. 1995. Access to Medical Care and Health-Related Quality of Life for Low-Income Persons with Symptomatic Human Immunodeficiency Virus. Medical Care 33(7):739-754; Cunningham, William E., Ronald M. Andersen, Mitchell H. Katz, Michael D. Stein, et al. 1999. The Impact of Competing Subsistence Needs and Barriers on Access to Medical Care for Persons with Human Immunodeficiency Virus Receiving Care in the United States. Medical Care. 37(12):1270-1281; Katz, Mitchell H., Sophia W. Chang, Susan P. Buchbinder, Nancy A Hessol, et al. 1995. Health Insurance and Use of Medical Services by Men Infected with HIV. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology. 8(1):59-63; Shapiro, Martin F., Sally C. Morton, Daniel F. McCaffrey, J. Walton Senterfitt, et al. 1999. Variations in the Care of HIV-Infected Adults in the United States. Journal of the American Medical Association 281(24): 2305-2315.

²²Goldman, Dana P., Jayanta Bhattcharya, Daniel F. McCaffrey, Naihua Duan, et al. 2001. Effect of Insurance on Mortality in an HIV-Positive Population in Care. Journal of the American Statistical Association 96(455): 833-894.

²³Cooper-Patrick, Lisa, Rosa M. Crum, Laura A. Pratt, William W. Eaton, et al. 1999. The Psychiatric Profile of Patients with Chronic Disease Who Do Not Receive Regular Medical Care. International Journal of Psychiatry 29(2): 165-180; Sturm, Roland, and Kenneth B. Wells. 1995. How Can Care for Depression Become More Cost-Effective? Journal of the American Medical Association 273(1): 51-58.

²⁴McAlpine, Donna D., and David Mechanic. 2000. Utilization of Specialty Mental Health Care Among Persons with Severe Mental Illness: The Roles of Demographics, Need, Insurance, and Risk. Health Services Research 35(1): 277-282.

²⁵Institute of Medicine, 2002. Health Insurance is a Family Matter. The National Academies Press, Washington, D.C., pp. 136-7.

²⁶Institute of Medicine, 2002. Health Insurance is a Family Matter. The National Academies Press, Washington, D.C., p. 139.

²⁷Bernstein, Amy. 1999. Insurance Status and Use of Health Services by Pregnant Women. Washington, DC: March of Dimes.

²⁸Stafford, Randall. 1990. Cesarean Section Use and Source of Payment: An Analysis of California Hospital Discharge Abstracts. American Journal of Public Health 80(3):313-315.

²⁹Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press, pp.128-130.

³⁰Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press, pp. 111ff.

³¹Currie, Janet and Jonathan Gruber. 1996. Health Insurance Eligibility, Utilization of Medical Care and Child Health. Quarterly Journal of Economics 111(2):431-466; Szilagyi, Peter, Jack Zwanger, Lance Rodewald, Jane Holl, et al. 2000. Evaluation of a State Health Insurance Program for Low-Income Children: Implications for State Child Health Insurance Programs. Pediatrics 105(2): 363-371; Lave, Judy, Christopher Keane, Chyongchiou Lin, Edmund Ricci, et al. 1998. Impact of a Children's Health Insurance Program on Newly Enrolled Children. Journal of the American Medical Association 279(22):1820-1825.

³²Newacheck, Paul, Dana Hughes, and Jeffery Stoddard. 1996. Children's Access to Primary Care: Differences by Race, Income, and Insurance. Pediatrics 97(1): 26-32.

³³Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press, pp.IOM, 2:9 top.

Please note that EBRI's analysis defines children as individuals ages 0-17, whereas other sources may define children as ages 0-18. This difference accounts for the variance between the reported numbers of uninsured children, depending on the source and method of analysis.

Other Related Fact Sheets

Coverage Matters [2]

Coverage Matters for Families [3]

Communities Matter [4]

Societal Costs [5]