Barriers to care get higher when adults are ill, uninsured

Their greater medical needs, at higher costs, have implications for the debate about health coverage expansion.

By Amy Snow Landa, amednews staff. March 11, 2002.

Washington -- For working-age Americans with at least one chronic health condition, the lack of health insurance coverage presents a significant, even life-threatening, problem.

Those who lack coverage are three times more likely not to get the medical care they need than working-age adults with chronic conditions who have private insurance, according to research findings released last month by the Center for Studying Health System Change.

Who has insurance
Ill and uninsured
Links

One out of two uninsured adults age 18 to 64 with chronic conditions said they either could not get needed care or delayed getting needed care at least once in the previous year, according to HSC. The findings are based on a national survey conducted in 1998-99.

Without good access to health care, people with chronic conditions such as diabetes, heart disease and hypertension are at higher risk for serious disability.

"I have treated diabetics who have postponed care for so long that they are legally blind," said Margarita Pereyda, MD, who serves as the medical director of the South Country Community Health Center in East Palo Alto, Calif.

In fact, almost 40% of uninsured adults with chronic conditions reported they were in fair or poor health -- more than twice the rate of those with private insurance.

7.4 million working-age adults with chronic conditions were uninsured in 1999.

Uninsured adults with chronic conditions also tend to have low incomes, which means the treatment they need is often unaffordable.

About 7.4 million working-age adults with chronic conditions were uninsured in 1999, according to the study. Nearly two-thirds of them had incomes below 200% of the federal poverty level, which is $17,720 a year for an individual and $30,040 for a family of three.

"As the study shows, cost is the major barrier to care for uninsured people with disabilities," said Don Young, MD, president of the Health Insurance Assn. of America.

But insuring them is also expensive -- a factor that could have significant implications for current debate among federal and state policy-makers over expanding health care coverage to more of the uninsured.

Policy implications

Lawmakers are considering several different proposals for expanding health insurance coverage, but none of them focuses specifically on extending coverage to uninsured people with chronic conditions, the HSC study noted.

This has got to change, according to the study's authors, who found that 27% of the adult uninsured population has at least one chronic condition and 10% have two or more.

27% of the adult uninsured population has at least one chronic condition.

"Policy-makers should examine the impact of coverage proposals through a lens focused on low-income, uninsured people with chronic conditions," the study's authors wrote.

"Chronic conditions, by definition, entail the need for more costly and intensive health care services," the authors stated. "This element of known higher expenses, in excess of the standard insurance risk, causes conventional concepts of insurance and risk to break down when applied to people with chronic conditions."

Without factoring in the more expensive health care needs of people with chronic conditions, "the proposals are likely to fall short of reaching this vulnerable group," said Ha T. Tu, a co-author of the study.

For example, proposals to give people tax credits to buy insurance in the individual market are problematic for those with chronic conditions. Recent studies have shown that people with such ailments often encounter higher-than-usual premiums or are offered policies that exclude one or more of their conditions.

If tax credits are to provide meaningful help for people with chronic conditions, the credit amounts would have to be adjusted to reflect their higher expected health care costs, the study authors wrote.

Another approach to covering more of the uninsured would be broadening public insurance programs. One proposal, which would expand the State Children's Health Insurance Program to cover parents of eligible children, could cover about one-third of uninsured adults with chronic conditions, the study noted.

Almost two-thirds of those with chronic conditions could be covered by eliminating all Medicaid eligibility requirements except low income, but this approach would carry a high price tag and could encourage employers to drop private insurance, the authors stated.

ADDITIONAL INFORMATION:

Who has insurance

In 1999, there were an estimated 60 million working-age Americans with at least one chronic health condition.

71% Privately insured
14% Covered by Medicare and/or Medicaid
12% Uninsured
3% Other coverage, such as military insurance

Source: Center for Studying Health System Change

Ill and uninsured

Among working-age Americans with chronic conditions and without insurance:

About 50% said they could not get needed care or delayed seeking care at least once in the previous year.
About 25% did not see a doctor even once during the past year, compared with less than 10% of the insured.
Nearly 40% said they were in fair or poor health, compared with less than 20% of those with private insurance.

Source: Center for Studying Health System Change, 1998-99 Community Tracking Study Household Survey

Weblink

Center for Studying Health System Change report, "Triple Jeopardy: Low Income, Chronically Ill and Uninsured in America" (http://www.hschange.org/CONTENT/411/)