Lack of health insurance associated with decreased use of health care services

Higher-income adults without health insurance are nearly as likely as lower-income adults without insurance to not use recommended health care services such as cancer screening, cardiovascular risk reduction and diabetes management, according to a study in the May 3 issue of JAMA.

More than 45 million Americans - nearly one-fifth of the non-Medicare population lack health insurance. Lacking health insurance has serious negative health consequences, according to background information in the article. Research has demonstrated that uninsured adults are less likely than insured adults to receive preventive services, such as screening for breast, cervical or colorectal cancer and not receiving recommended treatment for chronic illnesses, such as diabetes, arthritis or hypertension. Although the uninsured comprise a range of income levels, little attention has been directed at higher-income uninsured adults and their patterns of care.

Joseph S. Ross, M.D., of Yale University, New Haven, Conn., and colleagues examined whether an increased income weakens the association between being uninsured and using fewer recommended health care services. The researchers analyzed data from the 2002 Behavioral Risk Factor Surveillance System, a nationally representative telephone survey of households regarding medical history, health behaviors and health care use. Participants were community-dwelling adults (n = 194,943; 50 percent women) aged 18 to 64 years in 2002.

The researchers found that use varied widely across different types of recommended services. Among cancer prevention services, 51 percent of eligible adults used colorectal cancer screening while 88 percent of eligible women used cervical cancer screening. Among cardiovascular risk reduction services, 38 percent of obese adults received weight loss counseling while 81 percent of eligible adults with cardiovascular disease used aspirin regularly. Among services for diabetes management, 33 percent of adults with diabetes received a pneumococcal vaccination while 88 percent had glycosylated (linked to glucose) hemoglobin measurement.

Health insurance and annual household income were both strongly associated with use of recommended health care services. Among higher-income adults, lacking insurance was associated with significantly decreased use of recommended health care services; increased income level did not weaken the association between being uninsured and using fewer recommended health care services for cancer prevention, cardiovascular risk reduction, or diabetes management.

"Our research may indicate that a greater proportion of uninsured than insured adults believe that the recommended health care services are not sufficiently beneficial either to purchase using out-of-pocket funds or to receive by enrolling in health insurance," the authors write.

The researchers add that the findings present two important policy implications to consider. "First, policy makers attempting to improve health and health care for the uninsured should recognize that targeting only the lower-income uninsured may miss some individuals experiencing the consequences of lacking health insurance. Second, if adults do not understand that these recommended health care services are of sufficient value, policy makers and physicians may need to improve educational strategies."

"The results of our study suggest that [proposed health care] reforms may increase the number of adults not receiving recommended health care; adults using out-of-pocket funds to purchase health care services, whether they are enrolled in health savings accounts, employer-sponsored high-deductible insurance plans, or plans with substantial cost sharing, may not purchase recommended chronic and preventive care at levels comparable with adults enrolled in traditional health insurance plans."


(JAMA. 2006;295:2027-2036. Available pre-embargo to the media at

Editor's Note: No external funding was used for this research project. Dr. Ross is a scholar in the Robert Wood Johnson Clinical Scholars Program at Yale University, sponsored by the Robert Wood Johnson Foundation.

Last updated: 30 Apr 2016
Last reviewed: By John M. Grohol, Psy.D. on 30 Apr 2016
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