1 in 4 Uninsured Americans with Chronic Conditions Can't Get Needed Care

National Study Shows Cost Puts Care Out of Reach for Many - Especially Low Income People

Feb. 20, 2002

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ASHINGTON, D.C.—At least 7.4 million working-age Americans with chronic conditions—including diabetes, heart disease and depression—lacked health insurance in 1999, and one in four reported they couldn’t get needed medical care at least once in the previous year, according to a new national study released today by the Center for Studying Health System Change (HSC).

Cost was the most-cited barrier to needed care for the uninsured with chronic conditions, and almost two-thirds—or about 4.7 million people—had incomes below 200 percent of poverty, or about $35,000 a year for a family of four in 2001, the study found.

"Almost 5 million Americans face the triple threat of low income, ongoing health problems and no health insurance. Yet, proposed coverage expansions at the federal level don’t specifically consider the needs of this high-risk group," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded solely by The Robert Wood Johnson Foundation.

The study’s findings are detailed in two new HSC Issue Briefs—Triple Jeopardy: Low Income, Chronically Ill and Uninsured in America and Options for Expanding Health Insurance for People with Chronic Conditions—available by clicking here.

Often perceived primarily as a problem of the elderly, chronic conditions are widespread among working-age Americans, with an estimated 60 million 18- to 64-year-olds having at least one chronic condition, according to HSC’s 1998-99 Community Tracking Study Household Survey, a nationally representative survey involving approximately 60,000 people in 33,000 families.

In 1999, 71 percent of working-age adults with chronic conditions were privately insured; Medicare and/or Medicaid covered 14 percent; 12 percent were uninsured and the remainder had other coverage such as military insurance. Unlike the elderly, working-age people with chronic conditions do not qualify for Medicare unless they have severe disabilities.

Uninsured working-age people with chronic conditions report being in worse health and having more functional limitations and are three times more likely not to get needed medical care than people with chronic conditions who are privately insured. Key study findings include:

• One out of two of the uninsured with chronic conditions said they either could not get or delayed needed care at least once in the previous year.
• Nearly 40 percent of the uninsured with chronic conditions were in fair or poor health, compared with less than 20 percent of the privately insured with chronic conditions.
• More than 25 percent of the uninsured with chronic conditions couldn’t get needed medical care at least once in the past year, compared with less than 10 percent of those with insurance.
• Nearly two-thirds (63 percent) of the uninsured with chronic conditions had incomes below 200 percent of poverty, compared with 18 percent of the insured.
• About 25 percent of the uninsured with chronic conditions did not see a doctor at least once in the past year, compared with less than 10 percent of the insured.

Without good access to ongoing care, people with chronic conditions are at higher risk for serious disability. A person with diabetes who doesn’t receive regular eye and foot exams, for example, has a much higher risk of blindness or amputation.

"Despite their greater needs, it is clear that the uninsured with chronic conditions generally receive significantly less medical care than insured people," said Marie C. Reed, M.H.S., an HSC health research analyst and study co-author.

Federal and state policy makers are debating different proposals to expand health insurance coverage, including refundable tax credits to help people buy coverage in the individual market or expansion of public insurance programs. However, none of these proposals focuses specifically on extending coverage to the uninsured with chronic conditions.

People with chronic conditions typically need more care than healthy people, and this element of known higher expense—above the standard insurance risk—causes conventional concepts of insurance and risk to break down when applied to people with chronic conditions.

"The study’s findings suggest that if coverage expansion proposals don’t factor in people with chronic conditions’ greater need for care, the proposals are likely to fall short of reaching this vulnerable group," said Ha T. Tu, M.P.A., an HSC health researcher and study co-author.

Most coverage expansion proposals under discussion would reach a limited number of the uninsured with chronic conditions. For example:

• People with chronic conditions are unlikely to be able to find affordable coverage in the individual insurance market unless subsidies are adjusted to reflect their higher expected medical costs.
• Subsidies targeted at workers to help them pay their share of premiums would reach few of the uninsured with chronic conditions because less than one in five has access to employer-sponsored insurance.
• Subsidies targeted at small employers—fewer than 50 workers—to encourage them to offer health insurance might reach 40 percent of the uninsured with chronic conditions because they either work or have a family member working for a small firm not offering insurance. But other HSC research shows that employer-targeted subsidies would have to be large to induce small firms to offer coverage to workers. See Issue Brief.
• An expansion of the State Children’s Health Insurance Program, known as SCHIP, to cover parents of eligible children might reach about a third of the uninsured with chronic conditions.
• Eliminating all Medicaid eligibility requirements except low income (200 percent of poverty) would extend coverage to almost two-thirds of the uninsured with chronic conditions but would carry a high price tag.

Mary Grealy, president, Healthcare Leadership Council, www.hlc.org
"This study confirms that health coverage makes a world of difference for people with chronic health conditions, making it possible for them to get the timely, comprehensive medical care they need. This has to be one of our nation’s foremost priorities, and we need to move decisively toward the range of private and public solutions that are necessary to address the complex needs of America’s diverse uninsured population."

Gail Shearer, director of health policy analysis, Consumers Union, www.consumersunion.org
"The study confirms that the absence of health insurance forces people who are chronically ill into a second-class medical system that does not provide them the care that they need. It is a timely reminder of the dangers of proposed public policies-such as tax credits-that could divide the healthy from the sick, leaving the chronically ill with even fewer health insurance options than they have today."

Don Young, M.D., president, Health Insurance Association of America, www.hiaa.org
"As the study shows, cost is the major barrier to care for uninsured people with chronic conditions. Medical costs are once again rising rapidly and will cause people to lose their health insurance. This is a major concern for all Americans, especially those with chronic conditions. Policy makers must consider this link between health care costs and lack of health insurance as proposals move forward."