martes, 9 de noviembre de 2010

Vital Signs: Health Insurance Coverage and Health Care Utilization — United States, 2006–2009 and January–March 2010



Vital Signs: Health Insurance Coverage and Health Care Utilization — United States, 2006–2009 and
January–March 2010

The increasing number of persons with no health insurance has implications both for individual health and U.S. societal costs. Because of cost concerns, millions of uninsured persons forgo some needed health care, which can lead to poorer health and greater medical expenditures. To assess the association between lack of health insurance and delaying or forgoing health care, CDC analyzed data from the National Health Interview Survey. The results indicated that persons aged 18–64 years with chronic conditions and no health insurance coverage were much more likely to forgo medical care than persons with the same conditions and continuous coverage, regardless of income level.







Vital Signs: Health Insurance Coverage and Health Care Utilization --- United States, 2006--2009 and January--March 2010
Early Release
November 9, 2010 / 59(Early Release);1-7


ABSTRACT

Background: The increasing number of persons in the United States with no health insurance has implications both for individual health and societal costs. Because of cost concerns, millions of uninsured persons forgo some needed health care, which can lead to poorer health and potentially to greater medical expenditures in the long term.

Methods: CDC analyzed data from the National Health Interview Survey (NHIS) for 2006, 2007, 2008, and 2009 and early release NHIS data from the first quarter of 2010 to determine the number of persons without health insurance or with gaps in coverage and to assess whether lack of insurance coverage was associated with increased levels of forgone health care. Data were analyzed further by demographic characteristics, family income level, and selected chronic conditions.

Results: In the first quarter of 2010, an estimated 59.1 million persons had no health insurance for at least part of the year before their interview, an increase from 58.7 million in 2009 and 56.4 million in 2008. Of the 58.7 million in 2009, 48.6 million (82.8%) were aged 18--64 years. Among persons aged 18--64 years with family incomes two to three times the federal poverty level (approximately $43,000--$65,000 for a family of four in 2009), 9.7 million (32.1%) were uninsured for at least part of the preceding year. Persons aged 18--64 years with no health insurance during the preceding year were seven times as likely (27.6% versus 4.0%) as those continuously insured to forgo needed health care because of cost. Among persons aged 18--64 years with diabetes mellitus, those who had no health insurance during the preceding year were six times as likely (47.5% versus 7.7%) to forgo needed medical care as those who were continuously insured.

Conclusions: An increasing number of persons in the United States, including those at middle income levels, have had periods with no health insurance coverage in recent years, which is associated with increased levels of forgone health care. Persons aged 18--64 years with chronic conditions and without consistent health insurance coverage are much more likely to forgo needed medical care than persons with the same conditions and continuous coverage.

Implications for Public Health Practice: Increasing the number of persons with continuous health insurance coverage can reduce the number of occasions that persons forgo needed health care, which can reduce complications from illness and avoidable long-term expenditures.

Millions of persons in the United States have no health insurance. In addition to paying for their health care out of pocket, uninsured persons often are charged significantly higher fees than insured persons for the same care because of insurance plan discounts negotiated with health-care providers (1). Consequently, uninsured persons forgo needed care, including preventive care, because of cost concerns (2,3). Absent or delayed health care can lead to poorer health and potentially to greater medical expenditures in the long term (4,5). Although Medicare provides near-universal health insurance coverage for persons aged ≥65 years, and expansions in Medicaid and the Children's Health Insurance Program have increased coverage for children in the United States, a substantial percentage of adults aged 18--64 years have experienced disruptions in access to health care during the past decade, including those with chronic conditions, who have a greater need for care than the general population (6). In this report, CDC uses NHIS data to assess the association between lack of health insurance coverage and delaying or forgoing health care.

Methods

NHIS data regarding health insurance status and health-care utilization were collected via in-person interviews of a sample of the noninstitutionalized civilian population. Persons were considered uninsured if they did not have private health insurance, Medicare, Medicaid, Children's Health Insurance Program insurance, a state-sponsored or other government-sponsored health plan, or a military plan. Persons also were defined as uninsured if they had only a private plan that paid for one type of coverage (e.g., injury, eye care, or dental care) or had only Indian Health Service coverage.* Participants were asked whether they had insurance at the time of interview; whether they had been uninsured for at least part (i.e., even if only 1 day) of the preceding 12 months and, if so, for how long; whether they had delayed or forgone health care because of cost in the preceding 12 months†; whether they had ever been diagnosed with hypertension, diabetes mellitus, or asthma; and whether they had a usual source of care. Persons reporting that they typically visited an emergency department were considered not to have a usual source of care.

Of the households contacted, 82.2% participated in the 2009 survey. The response rate from participants exceeded 98% for the questions that produced the findings in this report, except for questions on income and race/ethnicity. Multiple imputations were performed on family§ income and personal earnings data and hot-deck imputations were performed on race/ethnicity data to account for missing responses to these questions.¶ NHIS data were adjusted for nonresponse and weighted to provide national estimates of insurance status, usual source of care, and care utilization; 95% confidence intervals were calculated, taking into account the survey's multistage probability sample design. The Wald test and logistic regression analyses were used to identify the statistical significance of differences in care utilization between persons who were continuously insured and those with either a 1--3 month gap in coverage in the preceding 12 months or with no health insurance for >12 months before the interview. Insurance status, usual source of care, and care utilization were examined by age group, sex, race/ethnicity, income level, and the highest level of education attained in the family. Data from the final release 2009 NHIS and early release NHIS data (i.e., compiled before final data editing and weighting) for the first quarter of 2010 were analyzed. Additional data from NHIS for 2006, 2007, and 2008 were used for comparison purposes.

Results

In 2009, an estimated 58.7 million (19.5%) persons of all ages had no health insurance for at least part of the year preceding their interview (Table 1). Of these 58.7 million, 48.6 million (82.8%) were persons aged 18--64 years, and 9.5 million (16.2%) were persons aged ≤17 years. From 2008 to 2009, the number of children without coverage for at least part of the year decreased 5.0%, from 10.0 million to 9.5 million. In contrast, the number of adults aged 18--64 years in this same insurance category increased 5.7%, from 46.0 million to 48.6 million. In 2009, 25.7% of all adults aged 18--64 years were without coverage for at least part of the preceding year; 15.4% reported being uninsured for more than a year (Table 1).

In the first quarter of 2010, the estimated number of persons without coverage for at least part of the year increased by 400,000 (0.7%), from 2009 to 59.1 million. The number of persons aged 18--64 years without coverage for at least part of the year increased by 1.3 million (2.7%) to 49.9 million, and the number without coverage for more than a year increased by 1.3 million (4.5%) to 30.4 million (Table 1).

In 2009, among persons aged 18--64 years with family incomes two to three times the federal poverty level (approximately $43,000--$65,000 for a family of four),** 9.7 million (32.1%) were uninsured for at least part of the preceding year. Among persons aged 18--64 years with family incomes three to four times the federal poverty level (approximately $65,000--$87,000 for a family of four), 5.2 million (20.6%) were uninsured for at least part of the preceding year (Table 2). From 2006 to 2009, the largest increase of any income group in the number (from 8.0 million to 9.7 million) and percentage (27.8% to 32.1%) of adults aged 18--64 without insurance at some point during the prior year occurred among those with a family income of two to three times the federal poverty level.

Persons aged 18--64 years who were without health insurance for more than a year were approximately six times as likely (55.2% versus 9.3%) to not have a usual source of care, compared with those who were continuously insured (Table 3). Similarly, persons aged 18--64 years with no health insurance during the preceding year were seven times as likely (27.6% versus 4.0%) to forgo needed health care because of cost, compared with those continuously insured (Table 4). Persons aged 18--64 years with no health insurance during the preceding year were approximately six times as likely to forgo needed care if they had hypertension (42.7% versus 6.7%) or diabetes mellitus (47.5% versus 7.7%) and five times as likely (40.8% versus 8.0%) to forgo needed care if they had asthma, compared with those with continuous coverage who had the same chronic condition (Table 4).

Currently insured persons aged 18--64 years who had a 1--3 month gap in coverage during the preceding year were nearly twice as likely (16.4% versus 9.3%) to not have a usual source of care, and three times as likely (26.5% versus 7.1%) to delay care because of cost, compared with persons with continuous coverage (Table 3). Currently insured persons aged 18--64 years who had a 1--3 month gap in coverage during the preceding year were approximately four times as likely (16.4% versus 4.0%) to forgo needed care because of cost, compared with persons with continuous coverage (Table 4). Among persons aged 18--64 years with continuous coverage, those with family income less than or equal to twice the federal poverty level were twice as likely (7.7% versus 3.1%) to forgo needed care because of cost as those with continuous coverage and income greater than twice the poverty level (Table 4).

Among those aged 18--64 years with family income less than or equal to twice the federal poverty level, currently insured persons who had a 1--3 month gap in coverage during the preceding year were approximately three times as likely (21.0% versus 7.7%) to forgo needed health care, compared with those with continuous coverage. Among those with income greater than twice the poverty level, currently insured persons who had a 1--3 month gap in coverage during the preceding year were four times as likely (13.8% versus 3.1%) to forgo needed health care, compared with those with continuous coverage (Table 4). Currently insured persons aged 18--64 years who had a 1--3 month gap in coverage during the preceding year were approximately three times as likely to forgo needed care if they had hypertension (25.3% versus 6.7%), diabetes (30.8% versus 7.7%), or asthma (26.0% versus 8.0%), compared with those with continuous coverage who had the same chronic condition (Table 4).

Among persons aged 18--64 years, those who were uninsured at the time of the interview were approximately three times as likely to forgo needed care because of cost as those with Medicaid (26.3% versus 8.7%) at the time of interview and six times as likely to forgo needed care because of cost as those with private insurance (26.3% versus 4.2%) at the time of interview (Table 5). Persons aged 18--64 years living in a family in which no one had a high school diploma or equivalent were approximately four times as likely to forgo needed care because of cost as those living in a family with a holder of a graduate degree (16.3% versus 4.2%) (Table 5).

full-text (large size):
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm59e1109a1.htm?s_cid=mm59e1109a1_e

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