Journal of Health Care for the Poor and Underserved

Original Paper 41 NO INSURANCE, PUBLIC INSURANCE, AND PRIVATE INSURANCE: DO THESE OPTIONS CONTRIBUTE TO DIFFERENCES IN GENERAL HEALTH? BETH HAHN, Ph.D. Glaxo, Inc. ANN BARRY FLOOD, Ph.D. Dartmouth Medical School Abstract: This paper examines the validity of two of the basic assumptions made about health care insurance and health, namely that having any insurance is associated with better health and, in particular, that having public, welfare-based insurance has better health consequences for the poor than does having no insurance. These questions were addressed using data from the National Medical Expenditure Survey, a national household-based survey in 1987 of more than 36,000 people who were asked to report in detail about their medical care use and expenditures, health insurance coverage, and health and functional status. The results of the analysis indicate that being without insurance is associated with having poorer general health compared to persons with private insurance, and that the health of persons who qualify for public insurance is the poorest of any group—poorer even than those without insurance. Key words: Insurance, uninsured, general health Since the mid-1960s, the population in the United States aged 65 years or over has had universal access to health insurance through Medicare. However, the remainder of the population falls into one of three basic categories with respect to health insurance: (a) insured privately through employment of a family member or by individual purchase, (b) insured publicly through a welfare-based insurance Journal of Health Care for the Poor and Underserved · Vol. 6, No. 1 · 1995 42 Health Insurance Options (Medicaid) requiring eligibility by "category" (such as being a child of a particular age) and by family income, or (c) uninsured. Recent political debate has focused particularly on the third group: the approximately 36 million people under the age of 65 years who are uninsured.1 In many respects, this number underestimates the true magnitude of our population with inadequate health insurance. First, the estimate is based on the percentage of people who were uninsured during the first quarter of 1987. However, if the time frame is extended to include persons who were uninsured for all or part of 1987, the estimate of uninsured swells to nearly 48 million persons.1 Second, many people have coverage that is insufficient for meeting their needs.2 Third, a growing number of people report being unable to change their current insurance (and therefore their current job situation) because their medical needs would not be covered if they were to switch employers and enroll in a new insurance program with exclusionary clauses. Despite these broader definitions of the populace who experience insurance problems, most agree that the group deserving immediate policy attention is the subset who have no insurance. The overwhelming majority of the uninsured are fully employed (or are their dependents ) and have a low to moderate income. These people are not uninsured by choice; rather, they fall through the cracks of qualifying for mandated employer-based insurance or for public insurance and are unable to afford available options for private health insurance. Currently, there is a consensus that the failure of this group to be insured represents a public policy problem because health insurance is assumed to be the key to better health—perhaps at most by benefiting individuals' health directly, but at a minimum by enabling people affordable access to health care to seek care earlier, obtain more and better services, and take advantage of preventive care.4 But is this assumption correct? Evidence relating insurance to self-reported health. A large body of empirical work has established a relationship between being uninsured and reporting worse health.5"9 The majority of cross-sectional population studies were largely descriptive and did not control for demographic, initial health, and health care use differences in the populations being compared. One of the few studies that has investiBETH HAHN, Manager, International Pharmacoeconomic Research, Glaxo Inc., Five Moore Dr., Research Triangle Park, NC 27709. ANN BARRY FLOOD, Associate Professor, Center for the Clinical Evaluative Sciences, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH 03755-3863. Received February 14, 1994; revised September 19, 1994; accepted October 10, 1994. Hahn & Flood 43...