1. HEALTH CONSEQUENCES OF UNINSURANCE: RESEARCH FINDINGS & POLICY IMPLICATIONS John Z. Ayanian, M.D., M.P.P. Division of General Medicine Brigham and Womens 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 Funded by the Robert Wood Johnson Foundation 6 reports issued between October, 2001 and January, 2004 Main objectives: (1) 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

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

9. 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 INSTITUTE OF MEDICINE

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. 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 parents plan insurer goes out of business or cancels contract priced out of the market when premiums increase Gaining & Losing Coverage Adapted from Weissman and Epstein, 1994

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

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

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

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. 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 Public (Mis)perception

18. IOM Conceptual Framework for Assessing Effects of Health Insurance on Health Outcomes Obtaining Access to Health Care Health-Related Outcomes Individual & Family Level Resources (e.g., health insurance status, income) Characteristics Need Community Level Resources (e.g., health insurance coverage rates, safety net services) 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

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

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

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

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

23. Loss of Medicaid Coverage Worsens Hypertension Control UCLA Medical Center, 1983 Lurie et al., N Engl J Med 1986 Diastolic BP Baseline6 Months1 Year Lost Medicaid859591 Continued Medicaid908587 Those who lost Medicaid also lost regular doctor: 92% had regular doctor at baseline 40% at 6 months 50% at 1 year

24. Unfortunately you have what we call no insurance. The New Yorker, 1999

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

26. Free Care Improves Hypertension Control RAND Health Insurance Experiment, 1974-1982 Keeler et al., JAMA 1985 Change in BPFree–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

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. Insurance Status (1994 and 1996) Before Medicare (1996) (%) After Medicare (2000) (%) Change (1996 to 2000) (%) (95% CI) Continuously insured76.081.85.8 (3.0, 8.7) Intermittently uninsured57.771.213.5 (7.8, 19.1) Continuously uninsured45.766.821.1 (7.8, 34.5) Continuously insured – Intermittently uninsured 18.2 (3.9, 32.6) 10.6 (-6.6, 27.8) -7.6 (-16.9, 1.6) (p=0.10) Continuously insured – Continuously uninsured 30.3 (15.3,45.2) 15.0 (-2.5, 32.4) -15.3 (-29.9,-0.7) (p=0.04) McWilliams et al. JAMA, 2003 Mammography Before & After Medicare Coverage Health and Retirement Study, 1994-2000

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 respondents estimated propensity to be insured

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

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

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 on Uninsured Families 58 million Americans are uninsured or live with an uninsured family member Having even one uninsured family member jeopardizes a familys financial & emotional stability and well-being

37. IOM Findings on Uninsured 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. Families Where All Children Are Insured by Parental Coverage Two-Parent Families Single-Parent Families Percent Percent of Families with All Children Insured

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 Uninsurance Within 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. 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 Costs of Care for People Without Insurance

45. A nnual 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, 2003 Miller, 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 billion Based on Vigdor 2003 Loss of Health Capital

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

49. Excess deaths annually Delays/gaps in care, worse outcomes Fewer preventive & screening services Increased stress, less financial security Unstable providers, fewer specialty services 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

50. Lessons From the Past and Present 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

51. More Lessons Some states have made significant progress in reducing uninsurance within their boundaries, but still have large uninsured populations States do not have fiscal resources and legal flexibility to eliminate uninsurance

52. Projected Proportion of Non-Elderly Americans Who Will Be Uninsured Under Different Economic Assumptions Source: Custer and Ketsche

53. Solutions will require more than cosmetic changes… The Buffalo News, 2002

54. 1. Health care coverage should be universal. 2. Health care coverage should be continuous. 3. Health care coverage should be affordable to individuals and families. 4. Health insurance strategy should be affordable and sustainable for society. 5. Health care coverage should enhance health and well- being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable. IOM Principles to Eliminate Uninsurance

55. IOM Conclusions, 2004 U ninsurance concentrated among low-income workers and their families & communities Uninsured adults & children experience decreased access to care and worse health High rates of uninsurance have adverse consequences for families & communities National economic loss of health capital equals or exceeds marginal cost of equivalent care for uninsured Universal coverage will require Federal leadership and funding – but not necessarily Federal administration

56. IOM Recommendations, 2004 President and Congress should develop strategy to achieve universal coverage by 2010 Five IOM principles should be used to assess merits of current proposals and design strategies for extending coverage Until universal coverage achieved, federal and state governments should fund Medicaid and SCHIP to cover all persons currently eligible and maintain outreach and enrollment

57. FOR MORE INFORMATION FROM THE INSTITUTE OF MEDICINE ON CONSEQUENCES OF UNINSURANCE Visit the project website and download copies of 8-page summaries in English or Spanish at www.iom.edu/uninsured Order copies of Committee reports or read them online www.nap.edu