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Mortality in the Uninsured Compared With That in Persons With Public and Private Health Insurance

Mortality in the Uninsured Compared With That in Persons With Public and Private Health Insurance Abstract Objective: To compare mortality in persons with employer-provided health insurance, Medicare, Medicaid, military health benefits, other private health insurance, and no health insurance, before and after adjustment for income and employment status. Design: Cohort study using national survey data containing information on social, economic, and demographic factors and health insurance, with deaths identified through matching to the National Death Index resulting in a mortality follow-up period of 5 years. Setting: Noninstitutionalized population of the United States. Participants: Approximately 150 000 respondents to national surveys conducted by the US Bureau of the Census (Current Population Surveys), aged 25 to 64 years. Results: After adjustment for age and income, persons with Medicare and Medicaid had the highest mortality in comparison with those with employer-provided insurance, with relative risks generally greater than 2. With adjustment for age and income, persons without insurance had higher mortality than those with employer-provided insurance, with relative risks of 1.2 for white men and 1.5 for white women. These relationships held after adjustment for employment status, with the working uninsured showing mortality between 1.2 and 1.3 times higher than that of the working insured. Mortality was higher in those with lower incomes after adjustment for insurance status. Those with annual income of $10 000 or less per year had mortality about two times that of persons with incomes greater than $25 000 per year. Conclusion: Mortality was lowest in employed persons with employer-provided health insurance. The higher mortality in those with public insurance or with no insurance reflects an indeterminate mix of selection on existing health status and access to medical care.(Arch Intern Med. 1994;154:2409-2416) References 1. Winkelstein W. Medical care is not health care . JAMA. 1993;269:2504.Crossref 2. Hurowitz JC. Toward a social policy for health . N Engl J Med. 1993;329:130-133.Crossref 3. Adler NE, Boyce T, Chesney MA, Folkman S, Syme L. Socioeconomic inequalities in health . JAMA. 1993;269:3140-3145.Crossref 4. Rogot E, Sorlie PD, Johnson NJ, Glover CS, Treasure D. A Mortality Study of One Million Persons by Demographic, Social, and Economic Factors: 1979-1981 Follow-up . Bethesda, Md: National Institutes of Health; 1988. NIH publication 88-2896. 5. Rogot E, Sorlie PD, Johnson NJ, Schmitt C. A Mortality Study of 1.3 Million Persons by Demographic, Social, and Economic Factors: 1979-1985 Follow-up . Bethesda, Md: National Institutes of Health; 1992. NIH publication 92-3297. 6. US Bureau of the Census. The Current Population Survey: Design and Methodology . Washington, DC: Dept of Commerce; 1978. Technical paper 40. 7. Moyer ME. A revised look at the number of uninsured Americans . Health Affairs. 1989;8:102-110.Crossref 8. National Center for Health Statistics. National Death Index Users Manual . Hyattsville, Md: Dept of Health and Human Services; 1990. DHHS publication (PHS) 90-1148. 9. Wentworth DN, Neaton JD, Rasmussen WL. An evaluation of the Social Security Administration Master Beneficiary Record file and the National Death Index in the ascertainment of vital status . Am J Public Health. 1983;73:1270-1274.Crossref 10. Stampfer MJ, Willett WC, Speizer FE. Test of the National Death Index . Am J Epidemiol. 1984;119:837-839. 11. Williams BC, Demitrack LB, Fries BE. The accuracy of the National Death Index when personal identifiers other than Social Security number are used . Am J Public Health. 1992;82:1145-1147.Crossref 12. Calle EE, Terrell DT. Utility of the National Death Index for ascertainment of mortality among Cancer Prevention Study II participants . Am J Epidemiol. 1993; 137:235-241. 13. World Health Organization. International Classification of Diseases: Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, Ninth Revision . Geneva, Switzerland: World Health Organization; 1977. 14. Ulm K. A simple method to calculate the confidence interval of a standardized mortality ratio (SMR) . Am J Epidemiol. 1990;131:373-375. 15. Lee ET. Statistical Methods for Survival Data Analysis . 2nd ed. New York, NY: John Wiley & Sons Inc; 1992. 16. Friedman E. The uninsured: from dilemma to crisis . JAMA. 1991;265:2491-2495.Crossref 17. Burwell BO, Rymer MP. Trends in Medicaid eligibility, 1975-1985 . Health Affairs. 1987;6:30-45.Crossref 18. Ries PW. Health care coverage by sociodemographic and health characteristics, United States, 1984 . In: Data From the National Health Survey , Series 10, No. 162. Hyattsville, Md: Dept of Health and Human Services; 1987:1-69. DHHS publication (PHS) 87-1590. 19. Franks P, Clancy CM, Gold MR. Health insurance and mortality . JAMA. 1993; 270:737-741.Crossref 20. Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH. Termination of Medi-Cal benefits: a follow-up study one year later . N Engl J Med. 1986;314:1266-1268.Crossref 21. Patrick DL, Madden CW, Diehr P, Martin DP, Cheadle A, Skillman SM. Health status and use of services among families with and without health insurance . Med Care. 1992;30:941-949.Crossref 22. Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland . JAMA . 1992;268:2388-2394.Crossref 23. Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care . JAMA. 1992;268:2383-2387.Crossref 24. Franks P, Clancy CM, Gold MR, Nutting PA. Health insurance and subjective health status: data from the 1987 National Medical Expenditure Survey . Am J Public Health. 1993;83:1295-1299.Crossref 25. Council on Ethical and Judicial Affairs. Caring for the poor . JAMA . 1993;269: 2533-2537.Crossref 26. Ginzberg E, Ostow M. Beyond universal health insurance to effective health care . JAMA. 1991;265:2559-2562.Crossref 27. Feinstein JS. The relationship between socioeconomic status and health: a review of the literature . Milbank Q. 1993;71:279-321.Crossref 28. Haas JS, Udvarhelyi IS, Morris CN, Epstein AM. The effect of providing health coverage to poor uninsured pregnant women in Massachusetts . JAMA. 1993; 269:87-91.Crossref 29. Kim K, Moody PM. More resources: better health? a cross-national perspective . Soc Sci Med. 1992;34:837-842.Crossref 30. Vagero D. Inequality in health: some theoretical and empirical problems . Soc Sci Med. 1991;32:367-371.Crossref 31. Wilkinson RG. Income distribution and life expectancy . BMJ. 1992;304:165-168.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Mortality in the Uninsured Compared With That in Persons With Public and Private Health Insurance

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Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1994.00420210037005
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To compare mortality in persons with employer-provided health insurance, Medicare, Medicaid, military health benefits, other private health insurance, and no health insurance, before and after adjustment for income and employment status. Design: Cohort study using national survey data containing information on social, economic, and demographic factors and health insurance, with deaths identified through matching to the National Death Index resulting in a mortality follow-up period of 5 years. Setting: Noninstitutionalized population of the United States. Participants: Approximately 150 000 respondents to national surveys conducted by the US Bureau of the Census (Current Population Surveys), aged 25 to 64 years. Results: After adjustment for age and income, persons with Medicare and Medicaid had the highest mortality in comparison with those with employer-provided insurance, with relative risks generally greater than 2. With adjustment for age and income, persons without insurance had higher mortality than those with employer-provided insurance, with relative risks of 1.2 for white men and 1.5 for white women. These relationships held after adjustment for employment status, with the working uninsured showing mortality between 1.2 and 1.3 times higher than that of the working insured. Mortality was higher in those with lower incomes after adjustment for insurance status. Those with annual income of $10 000 or less per year had mortality about two times that of persons with incomes greater than $25 000 per year. Conclusion: Mortality was lowest in employed persons with employer-provided health insurance. The higher mortality in those with public insurance or with no insurance reflects an indeterminate mix of selection on existing health status and access to medical care.(Arch Intern Med. 1994;154:2409-2416) References 1. Winkelstein W. Medical care is not health care . JAMA. 1993;269:2504.Crossref 2. Hurowitz JC. Toward a social policy for health . N Engl J Med. 1993;329:130-133.Crossref 3. Adler NE, Boyce T, Chesney MA, Folkman S, Syme L. Socioeconomic inequalities in health . JAMA. 1993;269:3140-3145.Crossref 4. Rogot E, Sorlie PD, Johnson NJ, Glover CS, Treasure D. A Mortality Study of One Million Persons by Demographic, Social, and Economic Factors: 1979-1981 Follow-up . Bethesda, Md: National Institutes of Health; 1988. NIH publication 88-2896. 5. Rogot E, Sorlie PD, Johnson NJ, Schmitt C. A Mortality Study of 1.3 Million Persons by Demographic, Social, and Economic Factors: 1979-1985 Follow-up . Bethesda, Md: National Institutes of Health; 1992. NIH publication 92-3297. 6. US Bureau of the Census. The Current Population Survey: Design and Methodology . Washington, DC: Dept of Commerce; 1978. Technical paper 40. 7. Moyer ME. A revised look at the number of uninsured Americans . Health Affairs. 1989;8:102-110.Crossref 8. National Center for Health Statistics. National Death Index Users Manual . Hyattsville, Md: Dept of Health and Human Services; 1990. DHHS publication (PHS) 90-1148. 9. Wentworth DN, Neaton JD, Rasmussen WL. An evaluation of the Social Security Administration Master Beneficiary Record file and the National Death Index in the ascertainment of vital status . Am J Public Health. 1983;73:1270-1274.Crossref 10. Stampfer MJ, Willett WC, Speizer FE. Test of the National Death Index . Am J Epidemiol. 1984;119:837-839. 11. Williams BC, Demitrack LB, Fries BE. The accuracy of the National Death Index when personal identifiers other than Social Security number are used . Am J Public Health. 1992;82:1145-1147.Crossref 12. Calle EE, Terrell DT. Utility of the National Death Index for ascertainment of mortality among Cancer Prevention Study II participants . Am J Epidemiol. 1993; 137:235-241. 13. World Health Organization. International Classification of Diseases: Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, Ninth Revision . Geneva, Switzerland: World Health Organization; 1977. 14. Ulm K. A simple method to calculate the confidence interval of a standardized mortality ratio (SMR) . Am J Epidemiol. 1990;131:373-375. 15. Lee ET. Statistical Methods for Survival Data Analysis . 2nd ed. New York, NY: John Wiley & Sons Inc; 1992. 16. Friedman E. The uninsured: from dilemma to crisis . JAMA. 1991;265:2491-2495.Crossref 17. Burwell BO, Rymer MP. Trends in Medicaid eligibility, 1975-1985 . Health Affairs. 1987;6:30-45.Crossref 18. Ries PW. Health care coverage by sociodemographic and health characteristics, United States, 1984 . In: Data From the National Health Survey , Series 10, No. 162. Hyattsville, Md: Dept of Health and Human Services; 1987:1-69. DHHS publication (PHS) 87-1590. 19. Franks P, Clancy CM, Gold MR. Health insurance and mortality . JAMA. 1993; 270:737-741.Crossref 20. Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH. Termination of Medi-Cal benefits: a follow-up study one year later . N Engl J Med. 1986;314:1266-1268.Crossref 21. Patrick DL, Madden CW, Diehr P, Martin DP, Cheadle A, Skillman SM. Health status and use of services among families with and without health insurance . Med Care. 1992;30:941-949.Crossref 22. Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland . JAMA . 1992;268:2388-2394.Crossref 23. Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care . JAMA. 1992;268:2383-2387.Crossref 24. Franks P, Clancy CM, Gold MR, Nutting PA. Health insurance and subjective health status: data from the 1987 National Medical Expenditure Survey . Am J Public Health. 1993;83:1295-1299.Crossref 25. Council on Ethical and Judicial Affairs. Caring for the poor . JAMA . 1993;269: 2533-2537.Crossref 26. Ginzberg E, Ostow M. Beyond universal health insurance to effective health care . JAMA. 1991;265:2559-2562.Crossref 27. Feinstein JS. The relationship between socioeconomic status and health: a review of the literature . Milbank Q. 1993;71:279-321.Crossref 28. Haas JS, Udvarhelyi IS, Morris CN, Epstein AM. The effect of providing health coverage to poor uninsured pregnant women in Massachusetts . JAMA. 1993; 269:87-91.Crossref 29. Kim K, Moody PM. More resources: better health? a cross-national perspective . Soc Sci Med. 1992;34:837-842.Crossref 30. Vagero D. Inequality in health: some theoretical and empirical problems . Soc Sci Med. 1991;32:367-371.Crossref 31. Wilkinson RG. Income distribution and life expectancy . BMJ. 1992;304:165-168.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 14, 1994

References