and the presence of diabetes, hypertension, or heart disease, using propensity incomes, or those without diabetes or cardiovascular disease (Exhibits 3 …
LexisNexis Academic
2004 The People-To-People Health Foundation, Inc
Health Affairs
July, 2004 - August, 2004
LENGTH: 3335 words
TITLE: Health Insurance Coverage And Mortality Among The Near-Elderly;
Uninsured near-elderly people are at much greater risk of premature death
than their insured peers are
AUTHOR: J Michael McWilliams, Alan M Zaslavsky, Ellen Meara, and John Z
Ayanian
TEXT:
Uninsured near-elderly people may be particularly at risk for adverse
health outcomes We compared mortality of a nationally representative
cohort of insured and uninsured near-elderly people with stratification by
race; income; and the presence of diabetes, hypertension, or heart disease,
using propensity-score methods to adjust for numerous characteristics
Lacking health insurance was associated with substantially higher adjusted
mortality among adults who were white; had low incomes; or had diabetes,
hypertension, or heart disease Expanding coverage to the near-elderly
uninsured may greatly improve health outcomes for these groups
Many studies have demonstrated that uninsured American adults receive less
appropriate
care and fewer needed health services than their insured peers
[n1] Near-elderly people who are uninsured represent a particularly
vulnerable population [n2] The risks of experiencing major health problems
and incurring substantial medical expenses increase dramatically for people
ages 55-64, so the consequences of lacking insurance may be more severe
[n3] Furthermore, near-elderly uninsured people often face higher premiums
when acquiring health insurance and thus tend to be uninsured for longer
periods than younger adults [n4] Projected increases in the number of near-
elderly uninsured have motivated proposals to make coverage more affordable
for this group [n5]
A Medicare buy-in option allowing people to purchase Medicare coverage
before reaching age sixty-five, with subsidies for those with low incomes,
was proposed by the Clinton administration and more recently by Sen John
Edwards D-NC in the Democratic presidential primaries Health savings
accounts HSAs, enacted in the Medicare Prescription Drug, Improvement and
Modernization Act MMA of 2003, allow individuals and employers to make
tax-deductible contributions toward medical expenses President George W
Bush has proposed
tax credits for the low-income uninsured who buy nongroup
coverage As a presidential candidate, Sen John Kerry D-MA has proposed
tax credits for uninsured and near-elderly people buying coverage in a new
group insurance option based on the Federal Employees Health Benefits
Program FEHBP [n6]
Expansions in coverage are likely to increase the use of important clinical
services for the near-elderly uninsured, but the effects of lacking
coverage on health outcomes continue to be debated because of the analytic
challenges of inferring causal effects from observational data [n7] In the
few natural or randomized experiments on this topic, worse blood pressure
control was evident among lower- income people with hypertension who lost
coverage or who were assigned less extensive coverage [n8] Observational
studies have found increased mortality among uninsured adults relative to
their insured peers with specific conditions such as cancer, myocardial
infarction, or HIV infection, but only two national studies have compared
all-cause mortality among insured and uninsured people [n9] Furthermore,
both of these national studies ended seventeen years ago, and subsequent
advances in medical care
may have improved outcomes among people with
better access to health services [n10]
Therefore, in a nationally representative, longitudinal cohort of 8,736
near- elderly people, we compared mortality over eight years between those
who were privately insured and those who were uninsured in 1992 To
minimize potential confounding due to marked differences in numerous
observed demographic, socioeconomic, health, and behavioral
characteristics, we used rigorous propensity-score methods whose results
are less likely to be biased than those of standard regression models We
also assessed whether the association between insurance coverage and
mortality varied by race and ethnicity; income; or the presence of
diabetes, hypertension, or heart disease
Study Data And Methods
Study population We analyzed publicly available data from the Health and
Retirement Study HRS, a nationally representative, longitudinal survey
sponsored by the National Institute on Aging and conducted by the Institute
for Social Research at the University of Michigan [n11] This study
included noninstitutionalized adults in the forty-eight contiguous United
States who were born during 1931-1941, with oversampling of
blacks and
Hispanics and Florida residents In 1992 initial English or Spanish
interviews were conducted in 7,702 households 82 percent response rate,
yielding 9,825 participants
Among participants who completed the initial interview in 1992, we excluded
those who reported public coverage at this interview, because disability
influences eligibility for coverage by all large governmental programs
available to this age group, including Medicare, Medicaid, the Civilian
Health and Medical Program of the Uniformed Services CHAMPUS, now known as
TriCare, and the Department of Veterans Affairs VA Adults with public
insurance were likely to have qualifying medical conditions for example,
end-stage renal disease or disabilities not fully measured by the HRS that
could have biased our results Recipients of CHAMPUS or VA benefits who
also reported having private health insurance were included, because their
primary source of coverage was likely to be private insurance unrelated to
disability This study used publicly available, anonymous data, so the
Human Studies Committee of Harvard Medical School deemed it exempt from
review
Study variables Participants were classified as insured if they
reported
private employer-based or individually purchased health insurance in
1992, and otherwise as uninsured During the 1992 interview, participants
also reported all study variables included in adjusted analyses
Participants reported to be deceased by household contacts through 2000 n
613 or whose vital status could not be determined from household
contacts in 2000 n 562 were submitted by the HRS for matching to the
National Death Index NDI for 1992-2000 Participants with definite
matches to the NDI n 605 were considered deceased Participants with no
match n 333 or possible matches n 237 were considered alive in
2000 Very few of these participants were reported deceased by household
contacts thirteen or 39 percent of non- matches, and eight or 34 percent
of possible matches [n12]
Statistical analysis To control for substantial differences in observed
characteristics between insured and uninsured participants, we used
propensity-score methods [n13] We used logistic regression to predict
whether participants had private health insurance in 1992 as a function of
twenty-seven variables In addition to those listed in Exhibit 1, these
variables included household size, census
region, self- reported recent
change in health, work limits imposed by health, job stress, physical
effort required by job, daily alcohol consumption, exercise habits,
expected probability of survival to age seventy-five, and the number of
hospital stays in the prior twelve months [n14] The estimated probability
of being insured in 1992, the propensity score, was used to derive
individual weights equal to the probability of belonging to the opposite
insurance group
We used Cox proportional hazards survival analyses to conduct our principal
comparison of mortality by insurance status in 1992 Absolute differences
in un- adjusted and adjusted eight-year mortality rates were also
determined and tested for significance using chi-square tests
Comparisons of mortality by insurance status were stratified by race and
ethnicity, household income, and the presence or absence of diabetes,
hypertension, or heart disease Additional variables that may have
explained mortality differences between insured and uninsured Hispanic
adults US nativity, nonresponse in 2000, language of interview, years
lived in the United States, ethnic identification [Mexican, Puerto Rican,
Cuban, or other], and an
interaction between language and self-reported
health were included in the propensity-score analysis for Hispanics In
these stratified analyses, separate propensity-score models were fit for
each stratum to determine appropriate weights for adjustment In addition,
we performed a sensitivity analysis to assess whether differences in
unobserved characteristics between insured and uninsured adults might
explain observed differences in mortality [n15] All analyses accounted for
the complex survey design
Study Results
Characteristics of study cohort Of the 9,825 participants interviewed in
1992, we excluded 953 97 percent adults with public health insurance and
136 14 percent with missing data on insurance coverage Of the remaining
8,736 adults, 7,199 824 percent were privately insured and 1,537 176
percent were uninsured in 1992 Among adults privately insured in 1992,
109 percent reported they were uninsured in at least one biennial survey
through 2000 Among adults who were uninsured in 1992, the proportion of
respondents who reported being publicly or privately insured rose
progressively in the ensuing four surveys 466 percent, 584 percent, 661
percent, and 745 percent, as nearly
half reached age sixty-five and
became eligible for Medicare by 2000
Insured and uninsured adults in 1992 differed significantly across almost
all observed characteristics in unadjusted comparisons Exhibit 1 After
propensity- score adjustment, all observed characteristics were very
closely balanced between insured and uninsured adults
Mortality Exhibit 2 shows unadjusted eight-year mortality rates for
uninsured and insured adults, and rates adjusted for the propensity to be
insured Significant differences in adjusted eight-year mortality rates
were evident among white adults; adults with low incomes; and those with
diabetes, hypertension, or heart disease, but not among black adults,
Hispanic adults, adults with higher incomes, or those without diabetes or
cardiovascular disease Exhibits 3 and 4
Mortality was significantly greater for uninsured adults than insured
adults in an unadjusted proportional hazards analysis hazard ratio [HR]:
183; 95 percent confidence interval [CI]: 146, 229; p 001 and remained
significantly greater after adjustment for propensity scores HR: 143; 95
percent CI: 110, 185; p 009 In stratified survival analyses,
insurance coverage was associated with
significantly lower adjusted
mortality in white adults HR: 157; 95 percent CI: 116, 212, adults in
the lowest income quartile HR: 153; 95 percent CI: 111, 212, and
adults with diabetes, hypertension, or heart disease HR: 156; 95 percent
CI: 115, 210 all p 01, but not in adults with higher incomes HR:
127; 95 percent CI: 078, 206 or without these conditions HR: 122; 95
percent CI: 082, 180 Mortality did not differ statistically between
uninsured and insured non-Hispanic black adults HR: 108; 95 percent CI:
067, 175; p 73 or uninsured and insured Hispanic adults HR: 048; 95
percent CI: 018, 128; p 14
In a sensitivity analysis, we found that the presence of an unobserved
factor similar to smoking in prevalence approximately 25 percent of the
study cohort and its association with insurance status relative risk of
being uninsured equal to 166 would have to be associated with a relative
eight-year mortality risk of 265 for the association between insurance
status and mortality to become non- significant when further adjusted for
this unmeasured factor HR: 128; 95 percent CI: 099, 167; p 06 In
comparison, smoking was associated with a relative eight-year mortality
risk of
248
Discussion And Policy Implications
This nationally representative study demonstrated that uninsured near-
elderly people are at much greater risk of premature death than their
insured peers Although consistent with the conclusions of two previous
national studies, our findings provide more recent estimates of mortality
differences between privately insured and uninsured adults [n16] Based on
these adjusted eight-year mortality rates and an estimated 35 million
uninsured people ages 55-64 in 2002, more than 105,000 excess deaths in the
next eight years more than 13,000 annually may be attributable to the
present lack of insurance coverage among the near-elderly [n17] This
estimate would place uninsurance third on a list of leading causes of death
for this age group, below only heart disease and cancer [n18] This rapidly
growing age group is expected to more than double to 619 million about 20
percent of the US population by 2015 [n19] Taking this growth into
consideration and assuming a stable uninsurance rate 13 percent, the
annual number of excess deaths attributable to the lack of health insurance
may exceed 30,000 by 2015, more than the combined number of
deaths
attributable to stroke, diabetes, and lung disease in this age group
By focusing on the near-elderly, we assessed an age group that faces
greater risks of acute and chronic illnesses than younger people and is
thus more likely to benefit from effective medical care Findings from our
stratified analyses indicate that the increased mortality of uninsured
adults was concentrated among those with low incomes or with diabetes or
cardiovascular disease, which underscores the importance of effective
medical care for these groups However, near-elderly people with low
incomes or chronic illness typically face the greatest obstacles to
obtaining private health insurance if they do not qualify for public
coverage [n20]
Our findings suggest that expanding coverage to the near-elderly uninsured
may greatly reduce mortality for these vulnerable groups However, each of
the major policy options for expanding coverage in this age group must
address major challenges A Medicare buy-in option could reduce the number
of near-elderly uninsured people but would require sizable premium
subsidies to do so, since uninsured adults tend to have lower incomes
[n21] HSAs and tax deductions to purchase
nongroup insurance primarily
benefit higher-income people with high marginal tax rates Furthermore,
chronically ill people face higher deductibles and premiums in the nongroup
insurance market compared with those of healthy people, which pose
substantial barriers for those with low incomes even when tax credits are
available Tax credits alone, unless much greater than those proposed in
the Bush administrations federal budget for 2005, are therefore unlikely
to reduce substantially the number of uninsured near-elderly people [n22]
Tax credits proposed by Senator Kerry in his presidential campaign are more
generous and are coupled with a group insurance option that would likely be
more affordable than non- group insurance, and thus potentially more
effective in expanding coverage [n23] The incremental cost of providing
equivalent care to uninsured and insured Americans would likely be exceeded
by the economic value of sizable gains in health capital for people without
insurance [n24]
Mortality was surprisingly similar for insured and uninsured blacks in our
study, which suggests that insurance coverage alone may not reduce
mortality for near-elderly blacks Even with health
insurance, black adults
face greater barriers to care and receive lower-quality health care than
whites, which may result from inadequate communication or stereotyping,
subconscious biases, or clinical uncertainty among health care providers
[n25] Insurance may also be insufficient to overcome lifelong risk factors
for ill health and mortality, including income inequality and broader
discrimination experienced by black Americans [n26]
Adjusted mortality was nearly identical for white and Hispanic adults who
were insured, but mortality tended to be lower among uninsured Hispanics
relative to insured Hispanics In general, Hispanic adults have a worse
socioeconomic profile but experience lower mortality than non-Hispanic
adults in the United States [n27] Several theories regarding this
epidemiological paradox, such as better unobserved health among new
immigrants, may also explain the trend toward lower observed mortality
among uninsured Hispanic adults [n28] For example, because acculturation
at the group level occurs over several generations, variables that we
controlled for, such as language and time spent in the United States, may
not have fully captured differences in health
behavior between insured and
uninsured Hispanic adults [n29] The HRS may also have selectively enrolled
uninsured Hispanics with better health or access to care than those who
were not enrolled, thereby underestimating the actual mortality of this
group
Our analysis adjusted for numerous variables not present in the most
extensive prior study of this topic, including activities of daily living
ADLs and physical functioning, presence of chronic diseases or depressive
symptoms, marital status, veteran status, geographic region, wealth, and
job stress [n30] All of these variables differed significantly by
insurance status and have been independently associated with mortality
[n31]
Despite the breadth of variables included in this study and the use of
rigorous propensity-score methods, unobserved factors could have explained
our findings However, we adjusted for numerous variables directly related
to disability for example, job status, work limits imposed by health,
physical functioning, chronic conditions, and expected mortality, greatly
reducing the effect of actual or impending disability as a potential
confounder of the increased mortality associated with lacking insurance
Our
sensitivity analysis further demonstrated that the confounding effect
of unmeasured variables would have to be even greater than the impact of
smoking on mortality in our study for the increased mortality of uninsured
adults to become statistically nonsignificant
Our study had other potential limitations Self-reported data were used for
statistical adjustment; the accuracy of these data for insured and
uninsured adults should be evaluated in future studies In addition, our
analysis focused on insurance status in 1992 and did not address the
subsequent gains and losses in coverage experienced by many participants
Because continuity of health insurance may have a dose-related effect on
health, changes in coverage after 1992, particularly those related to
Medicare eligibility, may have attenuated the effect of observed insurance
status on mortality [n32] Our study, however, had limited statistical
power to compare the impact of gaining Medicare coverage on the mortality
of those who were previously insured or uninsured Future research could
assess this effect in a larger cohort of people followed well beyond age
sixty-five
Our study demonstrated greatly increased mortality among
the near- elderly
uninsured relative to their privately insured peers This finding was
evident among white adults; those with low incomes; and those with
diabetes, hypertension, or heart disease, which suggests that these groups
are most likely to experience health benefits of expanding insurance
coverage for uninsured people over age fifty Our study also indicates that
expanding health insurance coverage alone may not be sufficient to reduce
the increased mortality experienced by near-elderly blacks Reforms to
expand coverage, such as a Medicare buy-in program or tax credits to
purchase insurance, may produce sizable health benefits if they provide
affordable coverage for the near-elderly uninsured, particularly those with
low incomes or chronic illness
The authors are grateful to Robert Wolf for assistance with statistical
programming This study was supported by the Primary Care Research Fund of
Brigham and Womens Hospital
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LOAD-DATE: July 7, 2004
Source:pe4life.org
