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Chronic Conditions Widespread Among Working-Age Adults
Nonelderly adults with chronic conditions are more likely to have health insurance than people without chronic conditions-88 percent vs. 81 percent in 1999.1 At that time, 71 percent of working-age adults with chronic conditions were privately insured; 12 percent were uninsured; 14 percent were covered by Medicare and/or Medicaid; and the remainder had other coverage such as military insurance. Chronic conditions can range from mild to severe. In some cases, people with chronic conditions experience few limitations, while others cannot perform the normal tasks of daily living without help. Good access to preventive and ongoing medical care for people with chronic conditions can alleviate pain and suffering, improve productivity and minimize future health problems and related costs. For example, people with diabetes who do not receive routine preventive care, including eye exams, foot exams, glucose screenings, cholesterol screenings and blood pressure measurements, are at higher risk for blindness, kidney failure and amputations. And, health insurance coverage plays an important and well-documented role in improving access to medical care. The findings for this Issue Brief are based on an analysis of the 1998-99 CTS Household Survey. The survey asked respondents aged 18 to 64 whether they had been diagnosed with one of more than 20 chronic conditions and had seen a doctor in the past two years for the condition. The list of chronic conditions includes asthma, diabetes, arthritis, chronic obstructive pulmonary disease, heart disease, stroke, hypertension, high cholesterol, cancer (skin, lung, prostate, breast, colon), benign prostate enlargement, abnormal uterine bleeding, severe headaches, cataracts, HIV/AIDS and depression. Because the CTS list of conditions is not exhaustive, the estimate of the prevalence of chronic conditions is likely somewhat conservative. In comparison, 41 percent of working-age adults reported at least one chronic condition in the 1996 Medical Expenditure Panel Survey.2 Uninsured with Chronic Conditions in Worse Health
Nearly 40 percent of the uninsured with chronic conditions indicated they were in fair or poor health, compared to less than 20 percent of the privately insured with chronic conditions. In addition, the uninsured were twice as likely to report having physical limitations that significantly restricted their ability to perform moderate activities such as moving a table or pushing a vacuum cleaner.
Figure 1
Uninsured Far Less Likely to Get Needed Care
The negative effects of being uninsured are substantially greater for working-age adults with chronic conditions than for those without any such conditions. The uninsured with chronic conditions were 3.3 times more likely not to obtain needed medical care than the privately insured, while the uninsured without chronic conditions were 2.7 times more likely not to obtain needed care-a 20 percent differential. The differential for delaying care was even greater-more than 35 percent.
Major Barrier to Care: Cost
The vast majority of the uninsured with chronic conditions who delayed or did not get needed care in the previous year did so because of cost concerns (see Figure 2). In contrast, less than half of the privately insured with chronic conditions who delayed care did so because of cost issues.
Figure 2 Health Care Services Received
For example, almost 25 percent of uninsured people with chronic conditions did not see a doctor at least once in the past year, compared to less than 10 percent of the privately insured. The uninsured reported an average of four doctor visits, about 30 percent fewer than those with private insurance. While the two groups had about equal numbers of hospital admissions on average, the uninsured underwent about half the number of surgeries, even after adjusting for health status, suggesting the uninsured with chronic illnesses may receive less intensive medical intervention. Lack of health insurance likely contributes to inappropriate use of emergency departments by people with chronic conditions, resulting in higher costs and possible capacity problems for the health care system. Compared to the privately insured, the uninsured with chronic conditions reported almost twice the number of emergency room visits.
Policy Implications
Overall, the uninsured with chronic conditions face more serious health problems and more barriers to needed care than insured people with chronic conditions. The long-term health implications of failing to receive preventive and ongoing medical care can be serious for people with chronic conditions. Indirect costs of chronic illness-lost workdays and sick pay-are considerable,5 and neglected care now may mean additional future productivity losses and costs to the economy. The added costs to the health care system are both immediate and long-term. Providing nonurgent care in emergency departments is more expensive than providing care in more appropriate sites. The relatively high use of emergency departments by the uninsured with chronic conditions can contribute to hospital capacity constraints that sometimes prompt emergency departments to divert ambulances to other hospitals. Moreover, difficulties obtaining care now may result in higher long-term demand for more expensive services if the lack of treatment results in more serious health problems for those with chronic conditions. Policy makers are debating different proposals to expand health insurance coverage, but none focuses specifically on the segment of the uninsured population with chronic conditions. Yet, because of their medical needs, people with chronic illnesses are precisely the ones who can benefit most from insurance coverage-especially if they also have low incomes. Given the significant human and economic costs of chronic illness, policy makers should consider and assess the impact of various coverage proposals on low-income, uninsured people with chronic conditions. The bottom line: health insurance counts for this vulnerable group. NotesISSUE BRIEFS are published by the Center for Studying Health System Change. President: Paul B. Ginsburg |
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