Use of Health Care Services by Lower-Income and Higher-Income Uninsured Adults
By Joseph S. Ross, MD, Elizabeth H. Bradley, PhD, and Susan H. Busch, PhD
JAMA
May 3, 2006
Our study provides recent, nationally representative estimates of the use of recommended services for cancer prevention, cardiovascular risk reduction, and diabetes management for insured and uninsured adults with varying annual household incomes. We found that high numbers of uninsured and lower-income adults are not receiving recommended care-challenging the views of a majority of people in the United States who believe that the uninsured are able to get the care they need from physicians and hospitals.
In addition, our findings indicate that even among higher-income adults, lacking insurance was associated with significantly decreased use of recommended health care services; we found that increased income did not attenuate the association between being uninsured and using fewer recommended health care services for cancer prevention, cardiovascular risk reduction, and diabetes management. The gap in the use of recommended care between uninsured and insured adults did not narrow significantly as income increased for any recommended service we examined. In fact, we found that the gap in the use of recommended care between uninsured and insured adults significantly widened as income increased for use of cervical and breast cancer screening, serum cholesterol screening, and eye examination and influenza and pneumococcal vaccination for diabetes management. In these cases, income not only failed to attenuate the association between being uninsured and using fewer recommended health care services, but the effect of lacking insurance was more pronounced for the higher-income uninsured than the lower-income uninsured. Moreover, when using the comparison between successive income levels rather than the trend across income, we found that for nearly every comparison, increased income did not significantly attenuate the association between being uninsured and using fewer recommended health care services. Thus, our findings are not limited to inferences regarding the highest-income uninsured, but are relevant for uninsured adults of all incomes.
Currently, many of the proposed health care reforms from both the public and private sector involve increased out-of-pocket cost-sharing or deductibles, such as the recent authorization of health savings accounts through the 2003 Medicare Modernization Act. The results of our study suggest that such reforms may increase the number of adults not receiving recommended health care; adults using out-of-pocket funds to purchase health care services, whether they are enrolled in health savings accounts, employer-sponsored high-deductible insurance plans, or plans with substantial cost sharing, may not purchase recommended chronic and preventive care at levels comparable with adults enrolled in traditional health insurance plans.
It is important to note that it is possible that in situations in which the net benefit to the individual is low, the net benefit to society may still be high.
http://jama.ama-assn.org/cgi/content/full/295/17/2027
Abstract:
http://jama.ama-assn.org/cgi/content/abstract/295/17/2027
Comment:
By Don McCanne, M.D.
There is no dispute. Regardless of income level, either the lack of insurance or excessive cost-sharing results in decreased utilization of clearly beneficial health services, with resultant impaired health outcomes.
Some contend that personal choice must prevail over all other considerations. If a person does not want to contribute funds to a risk pool (i.e., health insurance) then the individual should have the freedom to make that choice.
Others, including many conservatives, do not believe that health care costs should be shifted from “free riders” who do not contribute to risk pools, to the rest of us who will bear the cost of those who lose the bet they placed when they declined to participate. Most agree that some form of government intervention is required to be certain that would-be free riders contribute equitably to the costs.
Government precedence over individual choice is certainly not a new concept. We already have in place many requirements that are designed to protect the public from the costs of individuals who make bad choices. Seat belt and helmet laws protect society from financial losses due to injury of others. Auto insurance mandates also prevent free rider status by enforcing risk pooling.
This new study shows that individuals who can afford health insurance are avoiding care that can prevent health care spending that might well be shifted to the rest of us through higher taxes and insurance premiums. When speaking of rights, we should have the right to require that the free riders reduce our exposure to their potential monetary losses from their adverse health events.
Some of us are passionate supporters of national health insurance simply because we believe that everyone should have the right to affordable health care. For those who don’t really share this belief, just the simple concept of fairness dictates that we should eliminate free riders by including everyone in an equitably funded risk pool. And common business sense dictates that the most efficient and effective method would be through a single payer system. We should all be able to agree on this.