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August 11, 1993, Vol 270, No. 6 >
ARTICLE | August 11, 1993

Health Insurance and Mortality: Title and subTitle BreakEvidence From a National Cohort FREE

Peter Franks, MD; Carolyn M. Clancy, MD; Marthe R. Gold, MD, MPH
[+] Author Affiliations

The views expressed are those of the authors and do not reflect the official policy of the US Public Health Service or the Department of Health and Human Services.

Reprint requests to 885 South Ave, Rochester, NY 14620 (Dr Franks).


JAMA. 1993;270(6):737-741. doi:10.1001/jama.1993.03510060083037
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Article
References

Objective.  —To examine the relationship between lacking health insurance and the risk of subsequent mortality.

Design.  —Adults older than 25 years who reported they were uninsured or privately insured in the first National Health and Nutrition Examination Survey, a representative cohort of the US population, were followed prospectively from initial interview in 1971 through 1975 until 1987.

Participants.  —Complete baseline and follow-up information was obtained on 4694 (91%) persons of the 5161 who reported not receiving publicly funded insurance at baseline.

Main Outcome Measure.  —The relationship between insurance status and subsequent mortality was examined using Cox proportional hazards survival analysis. The analysis adjusted for gender, race, and baseline age, education, income, employment status, the presence of morbidity on examination, self-rated health, smoking status, leisure exercise, alcohol consumption, and obesity. The effects of interactions between insurance and all other baseline variables were also examined.

Results.  —By the end of the follow-up period, 9.6% of the insured and 18.4% of the uninsured had died. After adjustment for all other baseline variables, the hazard ratio for lacking insurance was 1.25 (95% confidence interval [Cl], 1.00 to 1.55). The effect of insurance on mortality was comparable to that of education, income, and self-rated health. There were no statistically significant (P<.05) interactions.

Conclusions.  —Lacking health insurance is associated with an increased risk of subsequent mortality, an effect that is evident in all sociodemographic health insurance and mortality groups examined.(JAMA. 1993;270:737-741)

REFERENCES

1 +
Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullinix CF, Corey CR.  Americans report on their access to health care. Health Aff . 1987;;6:6-8.
2 +
US Bureau of the Census. Money, Income of Households, Families, and Persons in the United States: 1991 . Washington, DC: US Bureau of the Census; 1992;. Series P-60, No. 180
3 +
Renner C, Navarro V.  Why is our population of uninsured and underinsured persons growing? the consequences of the 'deindustrialization' of America. Annu Rev Public Health . 1989;;10:85-94.
4 +
US Congress Office of Technology Assessment. Does Health Insurance Make a Difference? Washington, DC: US Congress Office of Technology Assessment; 1992;. Background paper OTA-BP-H-99.
5 +
Kleinman JC, Gold M, Makuc D.  Use of ambulatory medical care by the poor: another look at equity. Med Care . 1981;;19:1011-1029.
6 +
Newacheck PW.  Access to ambulatory care for poor persons. Health Serv Res . 1988;;23:401-419.
7 +
Freeman HE, Aiken LH, Blendon RJ, Corey CR.  Uninsured working-age adults: characteristics and consequences. Health Serv Res . 1990;;24:811-823.
8 +
Hafner-Eaton C.  Physician utilization disparities between the uninsured and insured: comparisons of the chronically ill, acutely ill, and well non-elderly populations. JAMA . 1993;;269:787-792.
9 +
Aday LA, Andersen RM.  The national profile of access to medical care: where do we stand? Am J Public Health . 1984;;74:1331-1339.
10 +
Hayward RA, Shapiro MF, Freeman HE, Corey CR.  Inequities in health services among insured Americans: do working-age adults have less access to medical care than the elderly? N Engl J Med . 1988;;318:1507-1512.
11 +
Weissman JS, Stern R, Fielding SL, Epstein AM.  Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;; 114:325-331.
12 +
Newacheck PW.  Improving access to health services for adolescents from economically disadvantaged families. Pediatrics . 1989;;84:1056-1063.
13 +
Braveman P, Bennett T, Lewis C, Egerter S, Showstack J.  Access to prenatal care following major Medicaid eligibility expansions. JAMA . 1993;; 269:1285-1289.
14 +
Woolhandler S, Himmelstein DU.  Reverse targeting of preventive care due to lack of health insurance. JAMA . 1988;;259:2872-2874.
15 +
Short PF, Lefkowitz DC.  Encouraging preventive services for low-income children: the effect of expanding Medicaid. Med Care . 1992;;30:766-780.
16 +
Billings J, Teicholz N.  Uninsured patients in District of Columbia hospitals. Health Aff . 1990;;9: 158-165.
17 +
Weissman JS, Gatsonis C, Epstein AM.  Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA . 1992;;268:2388-2394.
18 +
Weissman JS, Epstein AM.  Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area. JAMA . 1989;;261:3572-3576.
19 +
Hand R, Sener S, Imperato J, Chmiel JS, Sylvester JA, Fremgen A.  Hospital variables associated with quality of care for breast cancer patients. JAMA . 1991;;266:3429-3432.
20 +
Yergan J, Flood AB, Diehr P, LoGerfo JP.  Relationship between patient source of payment and the intensity of hospital services. Med Care . 1988;; 26:1111-1114.
21 +
Hadley J, Steinberg EP, Feder J.  Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA . 1991;;265:374-379.
22 +
Young GJ, Cohen BB.  Inequities in hospital care, the Massachusetts experience. Inquiry . 1991;; 28:255-262.
23 +
Greenberg ER, Chute CG, Stukel T, et al.  Social and economic factors in the choice of lung cancer treatment: a population-based study in two rural states. N Engl J Med . 1988;;318:612-617.
24 +
Wenneker MB, Weissman JS, Epstein AM.  The association of payer with utilization of cardiac procedures in Massachusetts. JAMA . 1990;;264:1255-1260.
25 +
Braveman P, Oliva G, Miller MG, Reiter R, Egerter S.  Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982 to 1986. N Engl J Med . 1989;; 321:508-513.
26 +
Lurie N, Ward NB, Shapiro MF, Brook RH.  Termination from Medi-Cal-does it affect health? N Engl J Med . 1984;;311:480-484.
27 +
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.
28 +
Fihn SD, Wicher JB.  Withdrawing routine outpatient medical services: effects on access and health. J Gen Intern Med . 1988;;3:356-362.
29 +
Brook RH, Ware JE Jr, Rogers WH, et al.  Does free care improve adults' health? results from a randomized controlled trial. N Engl J Med . 1983;; 309:1426-1434.
30 +
Hubbell FA, Waitzkin H, Rodriguez FI.  Functional status and financial barriers to medical care among the poor. South Med J . 1990;;83:548-550.
31 +
Patrick DL, Madden CW, Diehr P, Martin DP, Cheadle A, Skillman SM.  Health status and use of health services among families with and without health insurance. Med Care . 1992;;30:941-949.
32 +
Feldman JJ, Makuc DM, Kleinman JC,  CornoniHuntley J. National trends in educational differentials in mortality. Am J Epidemiol . 1989;;129: 919-933.
33 +
Gold MR, Franks P.  The social origin of cardiovascular risk: an investigation in a rural community. Int J Health Serv . 1990;;20:405-416.
34 +
House JS, Kessler RC, Herzog AR.  Age, socioeconomic status, and health. Milbank Q . 1990;; 68:383-411.
35 +
Marmot MG, Smith GD, Stansfeld S, et al.  Health inequalities among British civil servants: the Whitehall II study. Lancet . 1991;;337:1387-1393.
36 +
Burstin HR, Lipsitz SR, Brennab TA.  Socioeconomic status and risk for substandard medical care. JAMA . 1992;;268:2383-2387.
37 +
National Center for Health Statistics, Miller HW.  Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-73. Vital Health Stat [1] . No. (10a) , 10b.
38 +
National Center for Health Statistics, Engel A, Murphy RS, Maurer K, Collins E.  Plan and operation of the NHANES I Augmentation Survey of adults 25-74 years, United States, 1974-75. Vital Health Stat [1] . No. (14) .
39 +
National Center for Health Statistics, Cohen BB, Barbano HE, et al.  Plan and operation of the NHANES I Epidemiologic Follow-up Study, 1982-84. Vital Health Stat [1] . No. (22) .
40 +
Madans JH, Cox CS, Kleinman JC, et al.  10 years after NHANES I: mortality experience at initial follow-up, 1982-84. Public Health Rep . 1986;; 101:474-481.
41 +
Short PF, Cantor JC, Monheit AC.  The dynamics of Medicaid enrollment. Inquiry . 1988;;25: 504-516.
42 +
Madans JH, Kleinman JC, Cox CS, et al.  10 years after NHANES I: report of initial follow-up, 1982-84. Public Health Rep . 1986;;101:465-473.
43 +
Research Triangle Institute. SUDAAN: Professional Software for SUrvey DAta ANalysis .Version 6.20. Research Triangle Park, NC: Research Triangle Institute; 1992;.
44 +
Korn EL, Graubard BI.  Epidemiologic studies utilizing surveys: accounting for the sampling design. Am J Public Health . 1991;;81:1166-1173.
45 +
Franks P, Clancy CM, Gold MR, Nutting PA.  Health insurance and health status. Am J Public Health . 1993;. In press.
46 +
Short P, Monheit A, Beauregard K. A Profile of Uninsured Americans: National Medical Expenditure Survey Research Findings 1, National Center for Health Services Research and Health Care Technology Assessment . Rockville, Md: Public Health Service; 1989;. US Dept of Health and Human Services publication PHS 89-3443.
47 +
Farley PJ.  Who are the underinsured? Milbank Q . 1985;;63:476-503.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullinix CF, Corey CR.  Americans report on their access to health care. Health Aff . 1987;;6:6-8.
2 +
US Bureau of the Census. Money, Income of Households, Families, and Persons in the United States: 1991 . Washington, DC: US Bureau of the Census; 1992;. Series P-60, No. 180
3 +
Renner C, Navarro V.  Why is our population of uninsured and underinsured persons growing? the consequences of the 'deindustrialization' of America. Annu Rev Public Health . 1989;;10:85-94.
4 +
US Congress Office of Technology Assessment. Does Health Insurance Make a Difference? Washington, DC: US Congress Office of Technology Assessment; 1992;. Background paper OTA-BP-H-99.
5 +
Kleinman JC, Gold M, Makuc D.  Use of ambulatory medical care by the poor: another look at equity. Med Care . 1981;;19:1011-1029.
6 +
Newacheck PW.  Access to ambulatory care for poor persons. Health Serv Res . 1988;;23:401-419.
7 +
Freeman HE, Aiken LH, Blendon RJ, Corey CR.  Uninsured working-age adults: characteristics and consequences. Health Serv Res . 1990;;24:811-823.
8 +
Hafner-Eaton C.  Physician utilization disparities between the uninsured and insured: comparisons of the chronically ill, acutely ill, and well non-elderly populations. JAMA . 1993;;269:787-792.
9 +
Aday LA, Andersen RM.  The national profile of access to medical care: where do we stand? Am J Public Health . 1984;;74:1331-1339.
10 +
Hayward RA, Shapiro MF, Freeman HE, Corey CR.  Inequities in health services among insured Americans: do working-age adults have less access to medical care than the elderly? N Engl J Med . 1988;;318:1507-1512.
11 +
Weissman JS, Stern R, Fielding SL, Epstein AM.  Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;; 114:325-331.
12 +
Newacheck PW.  Improving access to health services for adolescents from economically disadvantaged families. Pediatrics . 1989;;84:1056-1063.
13 +
Braveman P, Bennett T, Lewis C, Egerter S, Showstack J.  Access to prenatal care following major Medicaid eligibility expansions. JAMA . 1993;; 269:1285-1289.
14 +
Woolhandler S, Himmelstein DU.  Reverse targeting of preventive care due to lack of health insurance. JAMA . 1988;;259:2872-2874.
15 +
Short PF, Lefkowitz DC.  Encouraging preventive services for low-income children: the effect of expanding Medicaid. Med Care . 1992;;30:766-780.
16 +
Billings J, Teicholz N.  Uninsured patients in District of Columbia hospitals. Health Aff . 1990;;9: 158-165.
17 +
Weissman JS, Gatsonis C, Epstein AM.  Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA . 1992;;268:2388-2394.
18 +
Weissman JS, Epstein AM.  Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area. JAMA . 1989;;261:3572-3576.
19 +
Hand R, Sener S, Imperato J, Chmiel JS, Sylvester JA, Fremgen A.  Hospital variables associated with quality of care for breast cancer patients. JAMA . 1991;;266:3429-3432.
20 +
Yergan J, Flood AB, Diehr P, LoGerfo JP.  Relationship between patient source of payment and the intensity of hospital services. Med Care . 1988;; 26:1111-1114.
21 +
Hadley J, Steinberg EP, Feder J.  Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA . 1991;;265:374-379.
22 +
Young GJ, Cohen BB.  Inequities in hospital care, the Massachusetts experience. Inquiry . 1991;; 28:255-262.
23 +
Greenberg ER, Chute CG, Stukel T, et al.  Social and economic factors in the choice of lung cancer treatment: a population-based study in two rural states. N Engl J Med . 1988;;318:612-617.
24 +
Wenneker MB, Weissman JS, Epstein AM.  The association of payer with utilization of cardiac procedures in Massachusetts. JAMA . 1990;;264:1255-1260.
25 +
Braveman P, Oliva G, Miller MG, Reiter R, Egerter S.  Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982 to 1986. N Engl J Med . 1989;; 321:508-513.
26 +
Lurie N, Ward NB, Shapiro MF, Brook RH.  Termination from Medi-Cal-does it affect health? N Engl J Med . 1984;;311:480-484.
27 +
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.
28 +
Fihn SD, Wicher JB.  Withdrawing routine outpatient medical services: effects on access and health. J Gen Intern Med . 1988;;3:356-362.
29 +
Brook RH, Ware JE Jr, Rogers WH, et al.  Does free care improve adults' health? results from a randomized controlled trial. N Engl J Med . 1983;; 309:1426-1434.
30 +
Hubbell FA, Waitzkin H, Rodriguez FI.  Functional status and financial barriers to medical care among the poor. South Med J . 1990;;83:548-550.
31 +
Patrick DL, Madden CW, Diehr P, Martin DP, Cheadle A, Skillman SM.  Health status and use of health services among families with and without health insurance. Med Care . 1992;;30:941-949.
32 +
Feldman JJ, Makuc DM, Kleinman JC,  CornoniHuntley J. National trends in educational differentials in mortality. Am J Epidemiol . 1989;;129: 919-933.
33 +
Gold MR, Franks P.  The social origin of cardiovascular risk: an investigation in a rural community. Int J Health Serv . 1990;;20:405-416.
34 +
House JS, Kessler RC, Herzog AR.  Age, socioeconomic status, and health. Milbank Q . 1990;; 68:383-411.
35 +
Marmot MG, Smith GD, Stansfeld S, et al.  Health inequalities among British civil servants: the Whitehall II study. Lancet . 1991;;337:1387-1393.
36 +
Burstin HR, Lipsitz SR, Brennab TA.  Socioeconomic status and risk for substandard medical care. JAMA . 1992;;268:2383-2387.
37 +
National Center for Health Statistics, Miller HW.  Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-73. Vital Health Stat [1] . No. (10a) , 10b.
38 +
National Center for Health Statistics, Engel A, Murphy RS, Maurer K, Collins E.  Plan and operation of the NHANES I Augmentation Survey of adults 25-74 years, United States, 1974-75. Vital Health Stat [1] . No. (14) .
39 +
National Center for Health Statistics, Cohen BB, Barbano HE, et al.  Plan and operation of the NHANES I Epidemiologic Follow-up Study, 1982-84. Vital Health Stat [1] . No. (22) .
40 +
Madans JH, Cox CS, Kleinman JC, et al.  10 years after NHANES I: mortality experience at initial follow-up, 1982-84. Public Health Rep . 1986;; 101:474-481.
41 +
Short PF, Cantor JC, Monheit AC.  The dynamics of Medicaid enrollment. Inquiry . 1988;;25: 504-516.
42 +
Madans JH, Kleinman JC, Cox CS, et al.  10 years after NHANES I: report of initial follow-up, 1982-84. Public Health Rep . 1986;;101:465-473.
43 +
Research Triangle Institute. SUDAAN: Professional Software for SUrvey DAta ANalysis .Version 6.20. Research Triangle Park, NC: Research Triangle Institute; 1992;.
44 +
Korn EL, Graubard BI.  Epidemiologic studies utilizing surveys: accounting for the sampling design. Am J Public Health . 1991;;81:1166-1173.
45 +
Franks P, Clancy CM, Gold MR, Nutting PA.  Health insurance and health status. Am J Public Health . 1993;. In press.
46 +
Short P, Monheit A, Beauregard K. A Profile of Uninsured Americans: National Medical Expenditure Survey Research Findings 1, National Center for Health Services Research and Health Care Technology Assessment . Rockville, Md: Public Health Service; 1989;. US Dept of Health and Human Services publication PHS 89-3443.
47 +
Farley PJ.  Who are the underinsured? Milbank Q . 1985;;63:476-503.

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