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HEALTH CONSEQUENCES OF UNINSURANCE: RESEARCH
FINDINGS & POLICY IMPLICATIONS
John Z. Ayanian, M.D., M.P.P.
Division of General MedicineBrigham and Women’s Hospital
Department of Health Care PolicyHarvard Medical School
January 16, 2004
Objectives of Presentation
Highlight analytic challenges of studying health effects of uninsurance
Present key findings of recent IOM reports on consequences of uninsurance
• Groups at risk
• Health effects for adults & children
• Social impact on families & communities
• Economic impact on the Nation
• Recommendations for extending coverage
Analytic Challenges
Simple cross-sectional analyses demonstrate associations, but not causal effects
Dynamic effects difficult to measure
Components of insurance effect and dose-responsenot well delineated
Standard analytic methods may overestimate orunderestimate effect of health insurance on health
(Hadley, Med Care Res Rev 2003)
Analytic Techniques
More rigorous analytic techniques can substantiallyreduce (though not eliminate) risk of unmeasuredconfounding
• Longitudinal data• Propensity scores• Difference in differences• Instrumental variables• Natural experiments
Randomized trials (e.g. RAND Health Insurance Experiment) unlikely in near future
Strength of observational inferences enhanced by:
• Clear conceptual framework for causal pathway
• Evidence for mediators of outcome effects Access to relevant care (HTN screening & awareness) Process measures (HTN therapy)
Intermediate endpoints (HTN control)
• Stratified analyses of high-risk subgroups & duration of uninsurance
Institute Of Medicine Committee on the Consequences of Uninsurance
Funded by the Robert Wood Johnson Foundation
6 reports issued between October, 2001 and January, 2004
Main objectives:
(1) To assess and synthesize evidence about the health, economic and social consequences of uninsurance
(2) To raise awareness and improve understanding among the general public and policy makers
IOM Reports
Report 1: Overview of Uninsurance (October, 2001)
Report 2: Health Consequences for Adults (May, 2002)
Report 3: Health and Economic Consequences for Families and Children (September, 2002)
Report 4: Health, Social and Economic Consequences for Communities (March, 2003)
Report 5: Social & Economic Consequences for the Nation (June, 2003)
Report 6: Insurance-Based Models and Strategies to Reduce the Consequences (January, 2004)
PersonalHealth
Concentric Consequencesof Uninsurance
National Social and Economic Costs
Family Well-being
Community Institutional Impacts & Quality of Life
Coverage Matters:
Insurance and
Health Care
Committee on the Consequences of UninsuranceBoard on Health Care Services, Institute of Medicinewww.nas.edu October, 2001
INSTITUTE OF MEDICINE
Goals of Health Insurance
Individuals & families: pooling financial risksand resources
• Access to providers of care• Protection from exceptional costs• Pre-payment for routine preventive services
Employers: Attracting and retaining workers
Providers: Ensuring payments and stable revenue
Government: Covering priority populations• Elderly, disabled, or poor• Pregnant women and children
How people gain coverage:
• get a job where insurance is offered & premiums affordable
• purchase insurance on your own, if you qualify
& premiums affordable
• marry someone with insurance & family premiums affordable
• qualify for Medicaid, SCHIP or Medicare by age, income, or disability
How people lose coverage:
• lose a job with insurance
• lose Medicaid or SCHIP eligibility as children grow up or family income rises
• lose spouse due to separation, divorce, or death
• reach age 18 or graduate from college and lose eligibility under parent’s plan
• insurer goes out of business or cancels contract
• priced out of the market when premiums increase
Gaining & Losing Coverage
Adapted from Weissman and Epstein, 1994
Probability of Being Uninsured for Population Under Age 65 by Census Region, 2001
Source: Fronstin, based on March 2001 Current Population Survey
Mountain18.6%
West North Central 10.6%
< 15%
15-20%
> 20%
Middle Atlantic15.0%
New England10.4%
South Atlantic16.9%
East NorthCentral12.9%
Pacific19.7%
East SouthCentral 14.6%
West South Central24.3%
Probability of Being Uninsured For Population Under Age 65,
By Race and Ethnicity, 1999
32.8
22.8
12.717.5
22.0
35.0
0
5
10
15
20
25
30
35
40
Hispanic AmericanIndian and
AlaskaNative
Non-HispanicAfrican
American
Asian-Americanand South
PacificIslander
Non-Hispanic
White
GeneralPopulationUnder Age
65
Un
insu
red
Rat
e (P
erce
nt)
Who is Most Likely to be Uninsured?
• Less than full-time, full-year employment or not in the labor force
• Earning less than 200 percent of federal poverty level ($34,000 for family of 4)
• No college education
• Employed by small firm (less than 100 workers) or self-employed; wholesale and retail trade, agriculture, forestry, fishing, mining, and construction sectors
Employment Status of Families of Uninsured Americans
=
Families with 1full-time worker
Families with 2 full-time
workers
Families with part-time workers
Families with noworkers 55.1%
15.7%
17.6%
11.6%
Familieswith workers
Families withno workers
82.4%
17.6%
INSTITUTE OF MEDICINE
Care Without Coverage:
Too Little, Too Late
Committee on the Consequences of UninsuranceBoard on Health Care Services, Institute of Medicinewww.nas.edu May, 2002
In 1999 57% of Americans believed that “uninsured people are able to get the care they need from physicians and hospitals.”*
(up from 43% in 1993)
*Blendon et al. Health Affairs, 1999
Public (Mis)perception
IOM Conceptual Framework for Assessing Effects of Health Insurance
on Health Outcomes
Obtaining Access to Health Care Health-Related Outcomes
Individual & FamilyLevel Resources(e.g., health insurancestatus, income)CharacteristicsNeed
Community LevelResources(e.g., health insurance coverage rates,safety net services)CharacteristicsNeed
Decision-making
• Individuals’ use of health services
• Provider management
• Patient- provider communication
Process of Care
• Presentation of illness or condition
• Prevention & early detection
• Quality of care
IntermediateOutcomes
• Timeliness of diagnosis
• Severity of illness at diagnosis
HealthOutcomes
• Subjective health status
• Clinical markers for specific conditions
• Mortality
Uninsured Adults in Poor or Fair Healthat Greatest Risk of Not Seeing a
Physician When Needed Due to Cost
Self-Reported Health Status
52
42
2519
11
2216
106 5
1623
31
49
69
0
20
40
60
80
100
Poor Fair Good Very Good Excellent
Uninsured > 1 year
Uninsured < 1 year
Insured
AdjustedPercent
Ayanian et al., JAMA 2000
Long-term Uninsured Adults inHigh-risk Clinical Groups Often HadNo Routine Check-up in Prior 2 Years
52
40 41
262822 20
7
2216 15
5
0
20
40
60
80
100
Smokers Binge Drinkers Obese Adults Diabetics
Uninsured > 1 year
Uninsured < 1 year
Insured
High-Risk Groups
AdjustedPercent
Ayanian et al., JAMA 2000
Deficits in Cardiovascular Risk Reduction
20
41
58
9
24
50
6
18
40
0
20
40
60
80
100
Blood PressureScreening
CholesterolScreening
SmokingCessation
Counseling
Uninsured > 1 year
Uninsured < 1 year
Insured
AdjustedPercent
(Age 25-64) (Age 45-64) (Age 18-64)
Ayanian et al., JAMA 2000
Undiagnosed Hypertension &Hypercholesterolemia Among Adults Age 25-64
National Health & Nutrition Examination Survey, 1988-1994
Ayanian et al., Am J Public Health, 2003
51
41
71
29
0
20
40
60
80
Hypertension Hypercholesterolemia
InsuredUninsured
PercentUndiagnosed
(Average BP 140/90) (Total cholesterol 240)
P=0.03
P=0.001
Loss of Medicaid CoverageWorsens Hypertension Control
UCLA Medical Center, 1983
Lurie et al., N Engl J Med 1986
Diastolic BP
Baseline 6 Months 1 Year
Lost Medicaid 85 95 91
Continued Medicaid 90 85 87
Those who lost Medicaid also lost regular doctor: 92% had regular doctor at baseline 40% at 6 months 50% at 1 year
“Unfortunately you have what we call ‘no insurance’.”
The New Yorker, 1999
Severe, Uncontrolled Hypertensionin Inner-City Emergency Departments
New York City, 1989-1991
Shea et al., N Engl J Med 1992
38
56
17 18
0
20
40
60
80
100
No Insurance No Primary Physician
Cases
Controls
Percent
Adjusted OR: 2.2
Adjusted OR: 4.0
Free Care Improves Hypertension ControlRAND Health Insurance Experiment, 1974-1982
Keeler et al., JAMA 1985
Change in BP Free–Care vs. Cost-Sharing*(mm/Hg) Low Income High Income
Systolic BP -2.2 -1.6
Diastolic BP -3.5 -1.1
*All P<0.05Free care led to:
Contact with physicians Detection and treatment of hypertension Compliance with care
Worse Cancer Outcomes
• Uninsured cancer patients more likely to die prematurely than insured patients, largely due to delayed diagnosis
• Uninsured women with breast cancer have 30-50% higher risk of death than privately insured women
• Uninsured women more likely to have late-stage diagnosis of cervical cancer than insured women
• Uninsured patients with colorectal cancer have 50-60% higher mortality rate than insured patients
Insurance Status(1994 and 1996)
Before Medicare
(1996) (%)
After Medicare
(2000) (%)
Change(1996 to 2000) (%) (95% CI)
Continuously insured 76.0 81.8 5.8 (3.0, 8.7)
Intermittently uninsured 57.7 71.2 13.5 (7.8, 19.1)
Continuously uninsured 45.7 66.8 21.1 (7.8, 34.5)
Continuously insured – Intermittently uninsured
18.2(3.9, 32.6)
10.6(-6.6, 27.8)
-7.6 (-16.9, 1.6)(p=0.10)
Continuously insured – Continuously uninsured
30.3 (15.3,45.2)
15.0(-2.5, 32.4)
-15.3 (-29.9,-0.7)(p=0.04)
McWilliams et al. JAMA, 2003
Mammography Before & After Medicare Coverage Health and Retirement Study, 1994-2000
Worse HIV Outcomes
• Uninsured adults with HIV infection less likely to receive highly effective drugs that improve survival • Having health insurance reduces the risk of dying within 6-month period by 70-85% among adults with HIV infection
Shapiro et al. JAMA, 1999
Goldman et al. JASA, 2001
8-Year Mortality Stratified by Income* Health and Retirement Study, 1992-2000
6.4
14.1
8.19.4
0
2
4
6
8
10
12
14
16
Lowest quartile of householdincome (n=2200)
Higher three quartiles ofhousehold income (n=6536)
8-Year Mortality (%)
Insured
Uninsured
P=0.01
P=0.40
* Results adjusted for each respondent’s estimated propensity to be insured
8-Year Mortality Stratified byChronic Conditions*
Health and Retirement Study, 1992-2000
4.5
12.5
5.4
18.8
0
5
10
15
20
Adults w/ DM, HTN, orHeart Disease (n=3562)
Adults w/o theseconditions (n=5174)
8-Year Mortality (%)
Insured
Uninsuredp=0.02
p=0.35
* Results adjusted for each respondent’s estimated propensity to be insured
Excess Mortality Among Uninsured AdultsIOM estimate, 2002
Risk of deathincreased by25%
18,000 excessdeaths annuallyin U.S.(ages 25-64)
1,300-1,400 deathsfrom hypertension
1,200-1,500 deathsfrom HIV infection
360-600 deathsfrom breast cancer
INSTITUTE OF MEDICINE
Health Insurance Is a
Family Matter
Committee on the Consequences of UninsuranceBoard on Health Care Services, Institute of Medicinewww.nas.edu September, 2002
Share of Household Income Required to Purchase Family Insurance Coverage, 2001
13.3%
20.0%
40.0%
100% FPL($17,650)
200% FPL($35,300)
300% FPL($52,950)
Worker's Portion (post-tax)Without Employer Subsidy($7,053)
IOM Findings onUninsured Families
• 58 million Americans are uninsured or live with an uninsured family member
• Having even one uninsured family member jeopardizes a family’s financial & emotional stability and well-being
IOM Findings onUninsured Children
• Uninsured children have worse access to care and worse health than insured children
• Over half of 8 million uninsured children are eligible for Medicaid or SCHIP programs
• When public insurance programs cover parents, their children are much more likely
to be enrolled
Families Where All Children Are Insured by Parental Coverage
44
95
32
66
98
0 20 40 60 80 100
Parent Not Insured
Parent Insured
No Adults Insured
One Adult Insured
Both Adults Insured
Two-Parent Families
Single-Parent Families
PercentPercent of Families with All Children Insured
INSTITUTE OF MEDICINE
A Shared Destiny:Community Effects
of Uninsurance
Committee on the Consequences of UninsuranceBoard on Health Care Services, Institute of Medicinewww.nas.edu March 2003
Access to Care in Communities with High Rate of Uninsurance
• Lessened availability of emergency medical services and trauma care, on-call specialty services and specialty referrals
• Strained capacity of community health centers to deliver primary care to all patients
Economic Impact of UninsuranceWithin Communities
• Weaker state and local capacity to finance uninsured care during economic recession
• Financial instability of health care institutions and providers can hurt local economy
Potential Impact of Uninsurance on Community Health
• Diminished control of vaccine-preventable and other communicable diseases (STDs, TB, HIV)
• Weakened emergency preparedness
• Funding shortfalls for population-based public health activities
INSTITUTE OF MEDICINE
Hidden Costs, Value Lost: Uninsurance in America
Committee on the Consequences of UninsuranceBoard on Health Care Services, Institute of Medicinewww.nas.edu June 2003
The cost of health services used by people who were uninsured in 2001 estimated to be $99 billion:
35% uncompensated care
38% covered by public & private insurance
27% paid out of pocket by those who lack coverage
Hadley & Holahan, Health Affairs, 2003
Costs of Care for People Without Insurance
Annual incremental cost of additional services that uninsured people would use if treated at same level as insured people:
$34 billion – $69 billion (2001 dollars)
Hadley & Holahan, 2003
Miller, Banthin & Moeller, 2003
Costs of Extending Coverage
Most of the costs of uninsurance are not health care costs:
Greatest economic losses due to uninsurance arise from worse health and shorter lives of those without coverage
For each year without coverage, an uninsured person experiences a health capital loss of $1,645–$3,280
(alternate assumptions about extent to which differences in health between insured and uninsured due to insurance coverage)
Total economic value of forgone health of 40 million uninsured for each year without coverage ranges between $65 billion – $130 billion
Based on Vigdor 2003
Loss of Health Capital
INSTITUTE OF MEDICINE
Insuring America’s Health: Principles and
Recommendations
Committee on the Consequences of UninsuranceBoard on Health Care Services, Institute of Medicinewww.nas.edu January 2004
Excess deaths annually
Delays/gaps in care, worse outcomes
Fewer preventive & screening services
Increased stress, less financial security
Unstable providers,
fewer specialty services
18,000
Acute illness
8 million uninsuredwith chronic illness
41 million uninsured adults & children
60 million uninsured families
Communities with high rates of uninsurance
Cumulative EffectsOf Uninsurance
Lessons From the Past and Present
• Efforts in 20th century yielded both incremental changes & major reforms, but not universal coverage
• Federal expansions over past 20 years targeted specific population groups but made little progress in reducing uninsurance nationally
More Lessons
• Some states have made significant progress in reducing uninsurance within their boundaries, but still have large uninsured populations
• States do not have fiscal resources and legal flexibility to eliminate uninsurance
Projected Proportion of Non-Elderly Americans Who Will Be Uninsured Under
Different Economic Assumptions
15%
16%
17%
18%
19%
20%
21%
22%
23%
24%
1994
1996
1998
2000
2002
2004
2006
2008
Mod. Econ Growth & Hlth Inflation Recession High Health Inflation
Source: Custer and Ketsche
Solutions will require more than cosmetic changes…
The Buffalo News, 2002
1. Health care coverage should be universal.
2. Health care coverage should be continuous.
3. Health care coverage should be affordable to individuals and families.
4. Health insurance strategy should be affordable and sustainable for society.
5. Health care coverage should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.
IOM Principles to Eliminate Uninsurance
IOM Conclusions, 2004
• Uninsurance concentrated among low-income workers and their families & communities
• Uninsured adults & children experience decreased access to care and worse health
• High rates of uninsurance have adverse consequences for families & communities
• National economic loss of health capital equals or exceeds marginal cost of equivalent care for uninsured
• Universal coverage will require Federal leadership and funding – but not necessarily Federal administration
IOM Recommendations, 2004• President and Congress should develop strategy
to achieve universal coverage by 2010
• Five IOM principles should be used to assess merits of current proposals and design strategies for extending coverage
• Until universal coverage achieved, federal and state governments should fund Medicaid and SCHIP to cover all persons currently eligible and maintain outreach and enrollment
FOR MORE INFORMATION FROM THE
INSTITUTE OF MEDICINE
ON CONSEQUENCES OF UNINSURANCE
• Visit the project website and download copies of 8-page summaries in English or Spanish at www.iom.edu/uninsured
• Order copies of Committee reports or read them online www.nap.edu
