HEALTH CONSEQUENCES OF UNINSURANCE: RESEARCH FINDINGS & POLICY IMPLICATIONS John Z. Ayanian, M.D., M.P.P. Division o

1. HEALTH CONSEQUENCES OF UNINSURANCE: RESEARCH FINDINGS & POLICY IMPLICATIONS John Z. Ayanian, M.D., M.P.P. Division of General Medicine Brigham and Women’s Hospital Department of Health Care Policy Harvard Medical School January 16, 2004

2. 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

3. Analytic Challenges Simple cross-sectional analyses demonstrate associations, but not causal effects Dynamic effects difficult to measure Components of insurance effect and dose-response not well delineated Standard analytic methods may overestimate or underestimate effect of health insurance on health (Hadley, Med Care Res Rev 2003)

4. Analytic Techniques • More rigorous analytic techniques can substantially • reduce (though not eliminate) risk of unmeasured • confounding • Longitudinal data • Propensity scores • Difference in differences • Instrumental variables • Natural experiments • Randomized trials (e.g. RAND Health Insurance Experiment) unlikely in near future

5. 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

6. Institute Of Medicine Committee on the Consequences of Uninsurance • 6 reports issued between October, 2001 and January, 2004 • Main objectives: • 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 Funded by the Robert Wood Johnson Foundation

7. 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)

8. Concentric Consequences of Uninsurance National Social and Economic Costs Community Institutional Impacts & Quality of Life Family Well-being Personal Health

9. INSTITUTE OF MEDICINE Coverage Matters:Insurance and Health Care Committee on the Consequences of Uninsurance Board on Health Care Services, Institute of Medicine www.nas.edu October, 2001

10. Goals of Health Insurance • Individuals & families: pooling financial risks • and 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

11. Gaining & Losing Coverage 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 Adapted from Weissman and Epstein, 1994

12. < 15% 15-20% > 20% Probability of Being Uninsured for Population Under Age 65 by Census Region, 2001 West North Central 10.6% East North Central 12.9% New England 10.4% Pacific 19.7% Middle Atlantic 15.0% South Atlantic 16.9% Mountain 18.6% East South Central 14.6% West South Central 24.3% Source: Fronstin, based on March 2001 Current Population Survey

13. Uninsured Rate (Percent) Probability of Being Uninsured For Population Under Age 65, By Race and Ethnicity, 1999

14. 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

15. Families with part-time workers Families with no workers 11.6% Families with no workers 17.6% 17.6% 55.1% = 15.7% 82.4% Families with 2 full-time workers Families with 1 full-time worker Families with workers Employment Status of Families of Uninsured Americans

16. INSTITUTE OF MEDICINE Care Without Coverage:Too Little, Too Late Committee on the Consequences of Uninsurance Board on Health Care Services, Institute of Medicine www.nas.edu May, 2002

17. Public (Mis)perception 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

18. Health-Related Outcomes Obtaining Access to Health Care Individual & Family Level Resources (e.g., health insurance status, income) Characteristics Need 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 Intermediate Outcomes • Timeliness of diagnosis • Severity of illness at diagnosis Health Outcomes • Subjective health status • Clinical markers for specific conditions • Mortality Community Level Resources (e.g., health insurance coverage rates, safety net services) Characteristics Need IOM Conceptual Framework for Assessing Effects of Health Insurance on Health Outcomes

19. Adjusted Percent Self-Reported Health Status Uninsured Adults in Poor or Fair Health at Greatest Risk of Not Seeing a Physician When Needed Due to Cost Ayanian et al., JAMA 2000

20. Adjusted Percent High-Risk Groups Long-term Uninsured Adults in High-risk Clinical Groups Often Had No Routine Check-up in Prior 2 Years Ayanian et al., JAMA 2000

21. Adjusted Percent (Age 25-64) (Age 45-64) (Age 18-64) Deficits in Cardiovascular Risk Reduction Ayanian et al., JAMA 2000

22. Percent Undiagnosed P=0.001 P=0.03 (Average BP  140/90) (Total cholesterol  240) Undiagnosed Hypertension &Hypercholesterolemia Among Adults Age 25-64National Health & Nutrition Examination Survey, 1988-1994 Ayanian et al., Am J Public Health, 2003

23. Loss of Medicaid CoverageWorsens Hypertension ControlUCLA Medical Center, 1983 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 Lurie et al., N Engl J Med 1986

24. “Unfortunately you have what we call ‘no insurance’.” The New Yorker, 1999

25. Percent Adjusted OR: 4.0 Adjusted OR: 2.2 Severe, Uncontrolled Hypertensionin Inner-City Emergency DepartmentsNew York City, 1989-1991 Shea et al., N Engl J Med 1992

26. Change in BP Free–Care vs. Cost-Sharing* (mm/Hg) Low IncomeHigh Income Systolic BP -2.2 -1.6 Diastolic BP -3.5 -1.1 *All P<0.05 Free care led to: • Contact with physicians • Detection and treatment of hypertension • Compliance with care Free Care Improves Hypertension ControlRAND Health Insurance Experiment, 1974-1982 Keeler et al., JAMA 1985

27. 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

28. Mammography Before & After Medicare Coverage Health and Retirement Study, 1994-2000 McWilliams et al. JAMA, 2003

29. 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

30. 8-Year Mortality Stratified by Income*Health and Retirement Study, 1992-2000 P=0.01 P=0.40 * Results adjusted for each respondent’s estimated propensity to be insured

31. 8-Year Mortality Stratified byChronic Conditions*Health and Retirement Study, 1992-2000 p=0.02 p=0.35 * Results adjusted for each respondent’s estimated propensity to be insured

32. 1,300-1,400 deaths from hypertension Risk of death increased by 25% 1,200-1,500 deaths from HIV infection 360-600 deaths from breast cancer Excess Mortality Among Uninsured AdultsIOM estimate, 2002 18,000 excess deaths annually in U.S. (ages 25-64)

33. INSTITUTE OF MEDICINE Health Insurance Is a Family Matter Committee on the Consequences of Uninsurance Board on Health Care Services, Institute of Medicine www.nas.edu September, 2002

34. Share of Household Income Required to Purchase Family Insurance Coverage, 2001

35. 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

37. 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

38. Two-Parent Families Single-Parent Families Percent Percent of Families with All Children Insured Families Where All Children Are Insured by Parental Coverage

39. INSTITUTE OF MEDICINE A Shared Destiny: Community Effects of Uninsurance Committee on the Consequences of Uninsurance Board on Health Care Services, Institute of Medicine www.nas.edu March 2003

40. 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

41. 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

42. 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

43. INSTITUTE OF MEDICINE Hidden Costs, Value Lost: Uninsurance in America Committee on the Consequences of Uninsurance Board on Health Care Services, Institute of Medicine www.nas.edu June 2003

44. Costs of Care for People Without Insurance 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

45. 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, 2003Miller, Banthin & Moeller, 2003 Costs of Extending Coverage

46. 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

47. 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 billionBased on Vigdor 2003 Loss of Health Capital

48. INSTITUTE OF MEDICINE Insuring America’s Health: Principles and Recommendations Committee on the Consequences of Uninsurance Board on Health Care Services, Institute of Medicine www.nas.edu January 2004

49. 18,000 Acute illness 8 million uninsured with chronic illness 41 million uninsured adults & children 60 million uninsured families Communities with high rates of uninsurance Cumulative Effects Of Uninsurance Excess deaths annually Delays/gaps in care, worse outcomes Fewer preventive & screening services Increased stress, less financial security Unstable providers, fewer specialty services

50. 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 Lessons From the Past and Present