Review 2 articles then develop summary points

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ORIGINAL CONTRIBUTION

Unmet Health Needs of Uninsured Adults in the United States John Z. Ayanian, MD, MPP Joel S. Weissman, PhD Eric C. Schneider, MD, MSc Jack A. Ginsburg, MPE Alan M. Zaslavsky, PhD

I N 1998, APPROXIMATELY 44 MILLION Americans younger than 65 years— nearly one fifth of the nonelderly population—lacked health insur-

ance, including 33 million adults aged 18 to 64 years.1 Prior studies have docu- mented that lacking health insurance is associated with important clinical con- sequences.2-4 Uninsured adults gener- ally encounter greater barriers to pre- ventive services and treatment of chronic illnesses than to acute care.5 They are more likely than insured adults to re- port poor health status,6-8 delay seeking medical care,9 and forgo necessary care for potentially serious symptoms.10 Un- insured adults receive fewer screening services for cancer and cardiovascular risk factors,11-14 present with later-stage diagnoses of cancer,15,16 and experience more avoidable hospitalizations.17 They also face an increased risk of death,18

particularly when hospitalized19 or diagnosed as having breast cancer.15

Although these studies provide com- pelling evidence of the adverse clini- cal consequences of being uninsured, most of them examined patterns of care and outcomes prior to 1990, before the rapid growth of managed care. Increas- ing competitive pressures in the US health care system over the past de- cade may be eroding access to care for the uninsured by reducing charity care provided by physicians20 and under- mining traditional safety-net provid- ers such as community health centers

and public hospitals.21-24 Several stud- ies have looked at the duration of pe- riods without health insurance25-28 or the effect of losing health insur- ance,29-31 but these studies have not dis- tinguished the clinical impact of short- term and long-term periods without insurance. In addition, few studies have

assessed the unmet needs of unin- sured adults with specific chronic con- ditions, such as diabetes32,33 or hyper- tension.34

Failing to monitor or effectively treat chronic illnesses such as hypertension in uninsured adults can result in substan- tial morbidity35,36 and may increase the

Author Affiliations: Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital (Drs Ayanian and Schneider), Department of Health Care Policy, Harvard Medical School (Drs Ayanian, Weissman, and Zaslavsky), Institute for Health Policy, Massachusetts General Hospital (Dr Weissman), and Department of Health Policy and Management, Harvard School of Public

Health (Dr Schneider), Boston, Mass; and the Ameri- can College of Physicians-American Society of Inter- nal Medicine (Mr Ginsburg), Washington, DC. Corresponding Author and Reprints: John Z. Ayanian, MD, MPP, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Bos- t o n , M A 0 2 1 1 5 ( e - m a i l : a y a n i a n @ h c p . m e d .harvard.edu).

Context In 1998, 33 million US adults aged 18 to 64 years lacked health insurance. Determining the unmet health needs of this population may aid efforts to improve access to care.

Objective To compare nationally representative estimates of the unmet health needs of uninsured and insured adults, particularly among persons with major health risks.

Design and Setting Random household telephone survey conducted in all 50 states and the District of Columbia through the Behavioral Risk Factor Surveillance System.

Participants A total of 105 764 adults aged 18 to 64 years in 1997 and 117 364 in 1998, classified as long-term ($1 year) uninsured (9.7%), short-term (,1 year) un- insured (4.3%), or insured (86.0%).

Main Outcome Measures Adjusted proportions of participants who could not see a physician when needed due to cost in the past year, had not had a routine checkup within 2 years, and had not received clinically indicated preventive services, com- pared by insurance status.

Results Long-term– and short-term–uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost (26.8%, 21.7%, and 8.2%, respectively), especially among those in poor health (69.1%, 51.9%, and 21.8%) or fair health (48.8%, 42.4%, and 15.7%) (P,.001). Long-term– uninsured adults in general were much more likely than short-term–uninsured and in- sured adults not to have had a routine checkup in the last 2 years (42.8%, 22.3%, and 17.8%, respectively) and among smokers, obese individuals, binge drinkers, and people with hypertension, elevated cholesterol, diabetes, or human immunodefi- ciency virus risk factors (P,.001). Deficits in cancer screening, cardiovascular risk re- duction, and diabetes care were most pronounced among long-term–uninsured adults.

Conclusions In our study, long-term–uninsured adults reported much greater un- met health needs than insured adults. Providing insurance to improve access to care for long-term–uninsured adults, particularly those with major health risks, could have substantial clinical benefits. JAMA. 2000;284:2061-2069 www.jama.com

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nation’s health care costs. These costs are absorbed by clinicians and facilities as free care, passed on to private insurers through cost shifting and higher fees, or paid by taxpayers through higher taxes to finance public hospitals and public in- surance programs. The more intensive medical care necessary to treat prevent- able complications of chronic illnesses may also be costly for the Medicare pro- gram when uninsured adults become eli- gible for this program at age 65 years. De- spite such effects, many Americans have perceived being uninsured as a tran- sient phenomenon without significant consequences.37,38 Understanding the un- met health needs of uninsured adults could help to overcome such views and bolster federal and state efforts to im- prove access to care.

We used nationally representative sur- vey data from the Behavioral Risk Fac- tor Surveillance System (BRFSS) for more than 100 000 adults in 1997 and 1998 to compare uninsured and insured adults’ access to physicians, especially among adults at increased risk for adverse health outcomes. We also examined rates of clinically indicated preventive services, including cancer screening, cardiovas- cular risk reduction, and diabetes man- agement. To assess the effect of longer and shorter periods without health in- surance, we differentiated adults unin- sured 1 year or longer from those unin- sured less than 1 year.

METHODS Data Source

The BRFSS is a federally funded sur- vey designed by the Centers for Dis- ease Control and Prevention (CDC) in collaboration with state health depart- ments to monitor health-related behav- iors and risk factors in the US popula- tion.39 Beginning with 15 states in 1984, the BRFSS has collected data annually through telephone interviews of adults aged 18 years or older residing in house- holds. Since 1994, all 50 states and the District of Columbia have adminis- tered the BRFSS survey and submitted survey data to the CDC.

The BRFSS survey instrument has 2 standardized components. First, a core

Table 1. Unadjusted Insurance Status of 18- to 64-Year-Old Adults in the United States Stratified by Demographic and Clinical Characteristics*

Characteristic

Estimated Population, in

Thousands

Uninsured, %

$1 y ,1 y Insured, %

All adults aged 18-64 y 163 538 9.7 4.3 86.0

Age, y 18-24 24 232 13.5 8.8 77.7

25-34 39 217 11.7 5.8 82.5

35-44 42 873 9.0 3.6 87.4

45-54 33 887 7.5 2.1 90.4

55-64 23 329 6.9 1.6 91.5

Sex Female 82 332 9.0 4.5 86.5

Male 81 207 10.4 4.1 85.5

Race/ethnicity White 119 559 7.4 3.5 89.2

Black 16 868 11.5 6.3 82.2

Hispanic 18 838 22.6 7.7 69.7

Asian or Pacific Islander 4748 8.5 4.6 86.9

American Indian or Alaskan Native 1647 12.4 4.8 82.9

Other 1243 16.4 5.0 78.7

Census region Northeast 31 604 7.4 4.0 88.6

South 57 694 11.9 5.0 83.1

Midwest 37 609 6.4 3.4 90.2

West 36 631 11.6 4.4 84.0

Employment Employed 108 457 7.1 3.4 89.5

Self-employed 14 375 19.9 4.9 75.2

Unemployed 7545 22.3 16.7 61.0

Not in labor force† 32 847 10.7 4.4 84.9

Education Less than high school graduate 18 339 26.0 6.7 67.3

High school graduate 52 491 11.3 5.5 83.2

1-3 y of college 46 262 7.4 4.1 88.5

$4 y of college 46 164 3.5 2.1 94.3

Annual household income ,$15 000 14 748 27.4 8.6 64.0

$15 000-24 999 25 554 19.0 8.5 72.5

$25 000-34 999 24 044 9.7 4.7 85.6

$35 000-49 999 29 793 3.9 2.6 93.5

$50 000-74 999 25 612 2.1 1.6 96.3

$$75 000 22 875 1.3 1.1 97.6

Do not know 9187 20.2 7.6 72.2

Refused 11 725 6.5 2.9 90.6

Self-reported health status Excellent 42 306 6.7 3.5 89.8

Very good 57 294 7.5 3.9 88.6

Good 44 843 12.3 5.1 82.6

Fair 14 381 17.9 5.5 76.6

Poor 4485 12.4 5.0 82.6

Current smoker Yes 41 849 13.7 6.4 79.9

No 121 353 8.3 3.6 88.1

Body mass index, kg/m2 $30 29 593 10.9 4.4 84.8

,30 127 968 9.2 4.3 86.6

UNMET HEALTH NEEDS OF THE UNINSURED

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set of questions is asked in all states an- nually (including health status, health insurance, presence of diabetes, smok- ing, breast and cervical cancer screen- ing, and human immunodeficiency vi- rus [HIV] risks) or biennially (eg, screening for hypertension, elevated cholesterol, and colorectal cancer, and influenza and pneumococcal vaccina- tions in 1997; weight control in 1998). Second, individual states may choose each year to include optional modules on topics such as diabetes manage- ment or preventive health counseling.

The survey instruments and proce- dures are designed to produce repre- sentative samples and ensure consis- tency of data across states and years. Many questions are derived from other national surveys, including the Na- tional Health and Nutrition Examina- tion Survey and the National Health In- terview Survey. English and Spanish versions of the 2 standardized compo- nents were provided by the CDC to each state. Additional information about BRFSS survey instruments and proce- dures is available from the CDC.40

Study Population The BRFSS used random-digit dialing within blocks of telephone numbers to

identify a probability sample of all households with telephones in each state. In eligible households, 1 adult aged 18 years or older was randomly selected and interviewed about his/ her health and medical care. Adults re- siding in hospitals, nursing homes, mili- tary bases, college dormitories, or prisons were not eligible. In 1997, the number of completed interviews per state ranged from 1505 to 4923 with a median estimated response rate of 62.5%. In 1998, completed interviews ranged from 1452 to 6005, with a me- dian response rate of 59.2%.40

Our cohort included adults aged 18 to 64 years from all 50 states and the Dis- trict of Columbia who completed the 1997 or 1998 BRFSS survey, including 105 764 respondents in 1997 and 117 364 in 1998. We defined uninsured adults as those who reported having no health insurance coverage at the time they were surveyed. We divided this group into the long-term uninsured (those who had been uninsured for $1 year) and the short-term uninsured (those who had been uninsured for ,1 year), consistent with other research us- ing BRFSS data.28 Respondents who re- ported having health insurance from any private or public source (including Medi-

care, Medicaid, and military or veter- ans’ coverage) were classified as in- sured. We excluded adults older than age 64 years because almost all are eligible for Medicare insurance. We also ex- cluded people who did not report their age (,0.5% in each year) or insurance coverage (,0.3%).

Study Variables We categorized the sample by numer- ous demographic variables, including age, sex, race/ethnicity, income, educa- tion, employment, and self-reported health status (TABLE 1). To focus on adults at increased risk for future health problems and early mortality,41,42 we identified respondents who reported cur- rent smoking, obesity (body mass in- dex [BMI] $30 kg/m2), hypertension (diagnosed by a health professional on at least 2 occasions), diabetes mellitus (diagnosed by a health professional, not including gestational diabetes), el- evated cholesterol (diagnosed by a health professional), binge drinking ($5 alco- holic drinks on at least 1 occasion in the past month), or self-perceived risk (me- dium or high) for HIV infection. Smok- ing, obesity, diabetes mellitus, and HIV risk were determined from the 1998 BRFSS survey. Hypertension, elevated cholesterol, and binge drinking were as- sessed in 1997 but not 1998. In Califor- nia, HIV risk was assessed only for people younger than age 45 years, so we limited analyses of this variable to people aged 18 to 44 years.

We studied 2 types of unmet health needs. The first type, inadequate ac- cess to physicians’ care, was defined as reporting “a time during the last 12 months when you needed to see a doc- tor, but could not because of the cost” and not having “visited a doctor for a routine checkup” during the prior 2 years. For the latter measure, we fo- cused on people with clinical risk fac- tors or chronic conditions who would most likely benefit from regular check- ups. The second type of unmet health need was failing to receive clinically in- dicated preventive services, defined as adequate, rather than optimal, care based on the recommended age range

Table 1. Unadjusted Insurance Status of 18- to 64-Year-Old Adults in the United States Stratified by Demographic and Clinical Characteristics* (cont)

Characteristic

Estimated Population, in

Thousands

Uninsured, %

$1 y ,1 y Insured, %

Hypertension‡ Yes 20 949 8.8 2.8 88.4

No 140 412 9.9 4.5 85.5

Elevated cholesterol‡ Yes 27 232 5.7 2.2 92.0

No 134 130 10.6 4.7 84.7

Diabetes mellitus‡ Yes 6608 8.0 3.0 89.0

No 156 766 9.8 4.3 85.9

Binge drinking‡ Yes 24 727 11.5 5.9 82.6

No 131 550 9.5 4.0 86.5

Human immunodeficiency virus risk‡§ Medium or high 8619 15.4 6.6 78.0

Not medium or high 97 704 10.6 5.5 83.9

*All data are based on the 1998 Behavioral Risk Factor Surveillance System survey except for data on hypertension, elevated cholesterol, and binge drinking, which are from the 1997 survey.

†Includes students, homemakers, retirees, and those not able to work. ‡See “Methods” section for definition. §Self-perceived risk among adults aged 18 to 44 years only.

UNMET HEALTH NEEDS OF THE UNINSURED

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and frequency in published national guidelines or evidence-based studies.

These preventive services included self-reported rates of cancer screening with mammography and clinical breast examinations within 2 years for women aged 50 to 64 years,43 Papanicolaou tests within 3 years for women aged 18 to 64 years with an intact uterus,43 fecal oc- cult blood testing with a home kit within 2 years for people aged 50 to 64 years,44-46

and sigmoidoscopy within 5 years for people aged 50 to 64 years.47-49 Cardio- vascular preventive services included hy- pertension screening within 2 years for all people aged 25 to 64 years,36 choles- terol screening within 5 years for all people aged 45 to 64 years,43,50-52 advice about weight loss by a health profes- sional within 1 year for obese individu- als aged 18 to 64 years,43 and advice about smoking cessation by a health profes- sional within 1 year for current smok- ers aged 18 to 64 years.43,53 Indicators of appropriate preventive services for per- sons with diabetes aged 18 to 64 years included receiving a glycosylated hemo- globin measurement, foot examination by a health professional, cholesterol mea- surement, and influenza vaccine within 1 year; dilated eye examination within 2 years; and pneumococcal vaccine at any time in the past.54-56 Screening for HIV at any time was evaluated for people aged 18 to 44 years who reported a medium or high risk of HIV infection.43

Information on preventive services was based on 1997 or 1998 data from all 50 states and the District of Columbia ex- cept for 4 services. Questions about gly- cosylated hemoglobin measurements and diabetic eye and foot examinations were asked during 1998 in 37 states, repre- senting about 70% of the US adult popu- lation. Questions about smoking cessa- tion counseling were asked during 1997 in 12 states, comprising about 25% of the US adult population.

Data Analysis Our analysis had 3 main objectives. First, in demographic and clinical strata we compared the proportions of respon- dents who were uninsured 1 year or longer, uninsured less than 1 year, and

insured. Second, we compared the pro- portions of these 3 groups that lacked ac- cess to care by a physician. Third, we cal- culated the proportion of each insurance group that had not received clinically in- dicated preventive services.

To assess the independent effect of lacking health insurance on access to physicians and preventive services, we used multiple logistic regression to con- trol for age, sex, race/ethnicity, census region, employment, education, and in- come. For all of these variables except income, data were missing for less than 0.5% of respondents, so we excluded these individuals from adjusted analy- ses. However, income data were miss- ing for 11.7% of the weighted sample in 1997 and 12.8% in 1998. To avoid po- tential biases due to mishandling of in- complete income data (eg, deleting cases or using indicator variables for missing data) and to make full use of the ob- served data,57-59 we used NORM statis- tical software to obtain multiple im- puted income values for respondents with missing data.60

These imputed data sets were ana- lyzed using conventional complete data techniques. We obtained adjusted rates of access measures for each category of insurance status (long-term uninsured, short-term uninsured, and insured) by direct standardization to the demo- graphic characteristics of the full study cohort using the logistic regression model.61,62 The BRFSS sampling and post- stratification weights were used in fit- ting the models and calculating ad- justed proportions. To derive accurate SEs and tests of statistical significance from these weighted data, we used SUDAAN statistical software63,64 and re- port 2-tailed tests of significance using standard procedures to calculate valid tests with multiply imputed data.65

RESULTS Characteristics Related to Insurance Status

The study population was representa- tive of more than 163 million US adults aged 18 to 64 years residing in house- holds during 1998 and approximately 161 million comparable adults in 1997.

In 1998, 9.7% of this population had been uninsured for at least 1 year, in- cluding 1.8% for 1 to 2 years, 2.1% for 2 to 5 years, 3.4% for more than 5 years, 2.1% who were never insured, and 0.3% who could not recall when they were last insured. An additional 4.3% of the population was uninsured for less than 1 year, including 2.5% for less than 6 months and 1.8% for 6 to 12 months. In 1997, 9.8% of the cohort had been uninsured for at least 1 year and 4.2% for less than 1 year.

The unadjusted proportion of adults in 1998 who were uninsured for 1 year or longer, uninsured less than a year, or insured are portrayed in Table 1, strati- fied by demographic and clinical char- acteristics. Compared with other adults in the cohort, the proportions of unin- sured individuals were higher among younger adults, men, blacks, Hispan- ics, residents of the South and West, those with less education and lower in- comes, and those who were self- employed, unemployed, or not in the la- bor force. Adults whose self-reported health status was good, fair, or poor were 2 to 3 times more likely to have been un- insured for 1 year or longer than those who reported excellent or very good health. Smokers, obese individuals, and binge drinkers were more often unin- sured than adults without these risk fac- tors. In contrast, people with self- reported hypertension, diabetes mellitus, and elevated cholesterol were less likely to be uninsured than adults without these conditions.

Access to Physicians TABLE 2 presents the unadjusted pro- portion of adults in each insurance cat- egory who could not see a physician when needed in the past year due to cost, stratified by demographic fac- tors. Nearly two fifths of long-term– uninsured adults and one third of the short-term–uninsured adults re- ported this problem, compared with only about 1 in 14 insured adults. Among long-term–uninsured adults, cost barriers to seeing a physician were greatest for women, blacks, the unem- ployed, and those with low incomes.

UNMET HEALTH NEEDS OF THE UNINSURED

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Adjusted proportions of uninsured and insured adults in clinical risk groups who could not see a physician when needed in the past year due to cost are shown in TABLE 3. In each of these risk groups, long-term– and short-term– uninsured adults were significantly more likely than insured adults to have expe- rienced cost barriers to needed care in the past year, reflecting the impact of even short-term periods without health insurance. As depicted in the FIGURE, 69.1% of long-term–uninsured adults in poor health and 48.8% of those in fair health reported they could not see a phy- sician when needed in the past year due to cost, compared with 51.9% and 42.4% of short-term–uninsured adults and 21.8% and 15.7% of insured adults, re- spectively.

TABLE 4 presents the adjusted pro- portions of uninsured and insured adults who did not have a routine checkup by a physician during the prior 2 years. In all clinical risk groups, long-term– uninsured adults were significantly more likely than insured adults to have lacked a routine checkup. For short-term– uninsured adults, the differences rela- tive to insured adults were smaller and significant only among smokers, obese individuals, and binge drinkers, but not among those with hypertension, diabe- tes, elevated cholesterol, or HIV risk.

Access to Clinically Indicated Preventive Services TABLE 5 shows the adjusted propor- tions of adults who did not receive ap- propriate preventive services. Long- term–uninsured adults were significantly more likely than insured adults to have unmet needs for each of these services, except for glycosylated hemoglobin mea- surements and pneumococcal vaccina- tions among adults with diabetes and HIV screening among those with self- perceived risk. For clinical services such as breast cancer or hypertension screen- ing, long-term–uninsured adults were 3 to 4 times more likely not to have re- ceived these services. Short-term– uninsured adults had intermediate rates of unmet needs for preventive services that were statistically higher than the

rates of insured adults for mammogra- phy, Papanicolaou tests, and hyperten- sion and cholesterol screening.

COMMENT Our study provides recent, nationally representative estimates of unmet health needs experienced by uninsured adults—two thirds of whom had been uninsured for 1 year or longer. Nearly

half of uninsured adults with annual in- comes below $15 000 reported they could not see a physician when needed in the past year due to the cost of care. Uninsured adults with clinically im- portant chronic conditions and health risks were much more likely than in- sured adults to report this problem, even after adjusting for income and other potential confounders. Alarm-

Table 2. Unadjusted Proportion of Uninsured and Insured Adults in the United States Who Could Not See a Physician When Needed in the Past Year Due to Cost*

Characteristic

Uninsured, %

Insured, %$1 y ,1 y

All adults aged 18-64 y 38.6 30.4 7.4

Age, y 18-24 35.5 24.3 8.9

25-34 36.0 29.9 9.0

35-44 41.8 34.5 7.4

45-54 42.6 37.5 6.5

55-64 38.7 37.5 5.1

Sex Female 47.7 37.9 8.9

Male 30.7 22.0 5.9

Race/ethnicity White 39.4 29.2 6.7

Black 43.6 38.1 8.8

Hispanic 36.0 31.1 11.9

Asian or Pacific Islander 28.8 10.5 5.6

American Indian or Alaskan Native 33.5 30.0 10.0

Other 39.2 41.5 12.2

Census region Northeast 41.8 26.6 6.0

South 39.7 33.1 8.4

Midwest 38.4 26.8 6.0

West 35.4 31.3 8.7

Employment status Employed 38.1 28.9 6.7

Self-employed 31.8 25.1 7.4

Unemployed 47.8 34.2 15.1

Not in labor force 41.5 33.4 8.7

Education Less than high school graduate 38.8 34.8 13.2

High school graduate 38.7 30.6 8.5

1-3 y of college 40.2 32.5 7.5

$4 y of college 35.6 20.4 4.6

Annual household income ,$15 000 47.7 46.2 19.8

$15 000-24 999 41.5 31.2 14.6

$25 000-$34 999 31.8 25.8 9.6

$35 000-49 999 30.3 22.9 5.5

$50 000-74 999 23.5 19.4 3.0

$$75 000 21.4 16.8 2.0

Do not know 35.0 26.8 8.6

Refused 32.4 28.5 5.8

*P,.001 for all 3-way comparisons in each stratum.

UNMET HEALTH NEEDS OF THE UNINSURED

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ingly high proportions of long-term– uninsured adults in poor or fair health reported forgoing needed care, includ- ing about two thirds of those in poor health and half of those in fair health. Another national survey has provided examples of the troubling personal nar-

ratives embodied in these statistics.66

These findings challenge the views of a growing proportion of Americans— from 43% in 1993 to 57% in 1999— who believe that uninsured people are able to get the care they need from phy- sicians and hospitals.37,38

Distinctive features of our study in- cluded a focus on the unmet health needs of long-term–uninsured adults, particu- larly those with impaired health or ma- jor chronic conditions such as diabetes mellitus, hypertension, and elevated cho- lesterol. Long-term–uninsured adults with these conditions and other clinical risk factors were much less likely than insured adults to have received routine checkups during which their health risks might have been addressed. In addi- tion, long-term–uninsured adults were less likely to report that they received ba- sic preventive services related to cancer screening and cardiovascular risk reduc- tion, but not HIV screening. The mag- nitude of these differences was greatest for services such as mammography and cholesterol screening that are often or- dered by primary care physicians dur- ing routine checkups. For routine check- ups and most preventive services, individuals who had been uninsured less than 1 year did not differ substantially from people who were insured, possi- bly because the short-term uninsured continued to have regular sources of care

or had received checkups while they were insured. In contrast, the short- term uninsured were similar to the long- term uninsured in the likelihood they had not seen a physician when needed in the past year due to cost, suggesting that even short-term periods without in- surance may cause sizeable numbers of people to forgo needed care.

Our study provides population- based rates of specific clinical services reported by uninsured and insured adults with diabetes mellitus, build- ing on 2 other national studies that ex- amined some of the same clinical ser- vices but did not distinguish the short- term and long-term uninsured.32,33

Although uninsured adults with dia- betes did not differ significantly from insured adults with diabetes in re- ported rates of glycosylated hemoglo- bin measurements or pneumococcal vaccinations, long-term–uninsured adults with diabetes were less likely than insured adults with diabetes to have received other basic services, such as eye and foot examinations, choles- terol screening, and influenza vaccina- tions. These results are particularly con- cerning because adults with diabetes mellitus face an increased risk of nu- merous complications, including seri- ous infections, cardiovascular disease, renal failure, and retinopathy, that can be prevented or deferred with effec- tive medical care.54 Therefore, improv- ing access to care for uninsured adults with diabetes may help prevent avoid- able complications of this serious chronic disease.

Our results are generally consistent with earlier reports that assessed the im- pact of insurance status on a narrower range of preventive services. Rates of breast and cervical cancer screening have increased substantially among un- insured women over the past 2 de- cades,11,12 perhaps in part because the National Breast and Cervical Cancer Early Detection Program has funded and promoted free screening services for uninsured, low-income women in all 50 states since 1991.67 However, the absolute differences in screening rates between uninsured and insured women

Figure. Adjusted Proportion of Uninsured and Insured Adults Who Could Not See a Physician When Needed in Past Year Due to Cost by Health Status

0 4020 60 80 Percentage

Self-reported Health Status

5.0 Excellent 10.5

15.7

6.4 Very Good 19.4

22.8

9.8 Good 24.8

30.5

15.7 Fair 42.4

48.8

21.8 Poor 51.9

69.1

Uninsured ≥1 y Uninsured <1 y Insured

Adjusted by direct standardization to the demo- graphic characteristics of the full study cohort in 1998, using logistic regression to control for age, sex, race/ ethnicity, region, employment status, education, and income. P#.001 for all 2-way comparisons of long- term–uninsured adults and short-term–uninsured adults with insured adults, respectively, in each category of health status. The numbers of respondents in each risk group can be computed from data in Table 1.

Table 3. Adjusted Proportion of Uninsured and Insured Adults in Clinical Risk Groups Who Could Not See a Physician When Needed in the Past Year Because of Cost*

Clinical Group

Uninsured, %

Insured, %$1 y† ,1 y†

All adults aged 18-64 y 26.8 21.7 8.2

Clinical risk group Current smoking 37.0 27.1 12.3

Body mass index $30 kg/m2 34.8 29.9 10.4

Hypertension 40.3 35.1 11.7

Diabetes mellitus 45.9 33.8 12.7

Elevated cholesterol 36.9 28.3 10.1

Binge drinking 29.1 27.6 8.7

Medium or high human immunodeficiency virus risk‡

33.7 23.0 11.5

*Adjusted by direct standardization to the demographic characteristics of the full study cohort, using logistic regres- sion to control for age, sex, race/ethnicity, region, employment status, education, and income. Behavioral Risk Fac- tor Surveillance System data from 1998 were used for all adults and for current smokers and those who reported body mass index of 30 kg/m2 or higher, diabetes mellitus, or human immunodeficiency virus risk; 1997 data were used for those who reported hypertension, elevated cholesterol, or binge drinking.

†P,.001 for all comparisons with insured adults. ‡Self-perceived risk among adults aged 18 to 44 years only.

UNMET HEALTH NEEDS OF THE UNINSURED

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have remained remarkably consistent when our findings are compared with earlier studies.11,12 Furthermore, an- other report based on BRFSS data found that age-adjusted mammography rates increased by about 6% for both in- sured and uninsured women between 1991-1992 and 1996-1997, but the ab- solute difference between these groups remained approximately 25%.68 Lower rates of cancer screening among unin- sured adults may be the principal rea- son why they are diagnosed at later, less curable stages of breast and colorectal cancer than insured adults.15,16

Although patchwork programs can fill gaps in specific services such as cancer screening for uninsured adults, na- tional health goals represented in the Healthy People 2010 objectives are un- likely to be met without more vigorous efforts to extend affordable health in- surance to the uninsured for a wide range of basic medical services.69 Four- teen states have taken steps to expand health insurance coverage for low- income adults.70 Evidence from 3 states (Minnesota, Oregon, and Tennessee) suggests these programs have helped re- duce both the prevalence and duration of periods without insurance for low- income adults.71 Comparable efforts to improve access by other states and the federal government could target long- term–uninsured adults with low in- comes or chronic health conditions and the approximately 2 million uninsured adults aged 55 to 64 years who are ap- proaching eligibility for Medicare, as oth- ers have suggested.37,72-75 Our findings suggest that the health benefits of ex- tending insurance to these groups could be substantial, but the costs borne by un- insured people must be low enough to encourage broad participation, espe- cially for those who are poor or near poor.76

Our study had some limitations. Al- though we focused on clinically impor- tant access measures that would be ex- pected to yield better health outcomes and are supported by national guide- lines, we did not analyze clinical out- comes or the effectiveness of specific treatments. Our study was a cross-

Table 4. Adjusted Proportion of Uninsured and Insured Adults in Clinical Risk Groups Who Did Not Have a Routine Checkup in the Past 2 Years*

Clinical Group

Uninsured, %

Insured, %$1 y ,1 y

All adults aged 18-64 y 42.8† 22.3† 17.8

Clinical risk group Current smoking 52.2† 27.6† 21.6

Body mass index $30 kg/m2 40.7† 20.0‡ 14.8

Hypertension 25.8† 13.9 10.3

Diabetes mellitus 25.5† 7.2 5.0

Elevated cholesterol 28.6† 10.4 10.5

Binge drinking 40.0† 22.2† 16.1

Medium or high human immunodeficiency virus risk§

44.0† 22.7 18.9

*Adjusted by direct standardization to the demographic characteristics of the full study cohort, using logistic regres- sion to control for age, sex, race/ethnicity, region, employment status, education, and income. Behavioral Risk Fac- tor Surveillance System data from 1998 were used for all adults and for current smokers and those who reported a body mass index of 30 kg/m2 or higher, diabetes mellitus, or human immunodeficiency virus risk; 1997 data were used for those who reported hypertension, elevated cholesterol, or binge drinking.

†P,.001 for comparison with insured adults. ‡P,.01 for comparison with insured adults. §Self-perceived risk among adults aged 18 to 44 years only.

Table 5. Adjusted Proportion of Uninsured and Insured Adults Who Did Not Receive Clinically Indicated Preventive Services*

Preventive Service Reference Period, y

Survey Year

Age Range, y

Uninsured, %

Insured, %$1 y ,1 y

Cancer screening Mammography† 2 1998 50-64 32.2‡ 21.3‡ 11.0 Clinical breast

examination† 2 1998 50-64 35.8‡ 17.5 10.7

Papanicolaou test§ 3 1998 18-64 19.5‡ 10.5‡ 6.3 Fecal occult blood testing

via home kit 2 1997 50-64 90.4‡ 80.5 75.3

Sigmoidoscopy 5 1997 50-64 89.3‡ 75.2 73.6 Cardiovascular risk reduction

Hypertension screening 2 1997 25-64 19.5‡ 8.6‡ 5.8 Cholesterol screening 5 1997 45-64 40.5‡ 24.0\ 18.1 Weight loss advice by

health professional¶ 1 1998 18-64 72.0‡ 67.2 64.1

Smoking cessation advice by health professional#

1 1997 18-64 58.4‡ 49.6 40.3

Diabetes management** Glycosylated hemoglobin

measurement 1 1998 18-64 83.2 73.0 75.0

Foot examination by health professional

1 1998 18-64 63.9‡ 41.8 40.4

Dilated eye examination 2 1998 18-64 43.6‡ 18.4 26.7 Cholesterol measurement 1 1997 18-64 30.2‡ 25.4†† 13.3 Influenza vaccine 1 1997 18-64 73.0\ 63.7 57.3 Pneumococcal vaccine Ever 1997 18-64 83.9 86.4 78.4

Human immunodeficiency virus screening‡‡

Ever 1998 18-44 51.5 46.6 44.7

†Among women. ‡P,.001 for comparison with insured adults. §Among women with intact uterus. \P,.01 for comparison with insured adults. ¶Among people with a body mass index of 30 kg/m2 or higher. #Among current smokers. **Among adults with diabetes. ††P#.05 for comparison with insured adults. ‡‡Among people with self-perceived medium or high human immunodeficiency virus risk.

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sectional analysis, so we could not di- rectly examine the effects on the unin- sured of the growth of managed care or other temporal changes in the health care system. In addition, the cross- sectional nature of BRFSS data did not allow us to link the timing of preven- tive services to specific periods in which individuals were uninsured. Our mea- sures were based on self-reported data that were not independently verified. The reliability of such self-reports is very good or excellent for most variables in- cluded in our study.77-80 Studies of the validity of self-reported data indicate that telephone surveys closely approximate the prevalence of diabetes and smok- ing obtained from clinical testing, but may underestimate rates of obesity, hy- pertension, and elevated cholesterol,81

and overestimate rates of mammogra- phy.82

We have no reason to expect sub- stantial differences in the accuracy of health data reported by uninsured and insured adults, particularly after we c o n t r o l l e d f o r n u m e r o u s d e m o - graphic confounders and used rigor- ous multiple-imputation methods to minimize potential bias related to miss- ing income data. However, our study may underestimate the unmet health needs of uninsured adults if they are less likely to be aware of important health conditions due to inadequate screen- ing. Even when uninsured adults with low incomes obtain care, they report that the quality and continuity of care is substantially worse than reported by insured low-income adults.31,74 The study cohort also did not include adults living in households without tele- phones, who represent about 5% of the US population and are more likely to be poor, black, Hispanic, and resi- dents of the South.39 Because these groups are more often uninsured than other groups of adults, our estimates of uninsured adults with deficits in basic care probably would increase if people without telephones had been in- cluded.

The federal and state governments have begun to extend affordable health insurance to uninsured children in the

United States by expanding Medicaid and launching the Children’s Health In- surance Program.3,83 In contrast, the un- met health needs of 33 million unin- sured adults continue to fester in the health care system without a cohesive political response by the federal gov- ernment or most states. Concerted and collaborative action by policymakers and health care professionals will be re- quired to address these persistent needs.

Funding/Support: This study was funded by the American College of Physicians-American Society of Internal Medicine. Acknowledgment: We are grateful to Robert E. Wolf, MS, for statistical programming, Recai Yucel, PhD, for imputing missing data, Whitney W. Addington, MD, and Robert B. Doherty for help in initiating this study, and Melinda Schriver for helpful comments on an ear- lier draft of the manuscript.

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