Access to Health Insurance, Health Disparities and Physical Well-Being

Access to Health Insurance, Health Disparities and Physical Well-Being

Health insurance is very much in the news right now.  Late on Monday, January 22, 2018, the United States Senate was able to pass a temporary budget that provided funding to the Children’s Health Insurance Program (CHIP), which provides health insurance to economically disadvantaged children.  During the first year of the presidency of Donald Trump, health insurance coverage under the Affordable Care Act (ACA; i.e., “Obamacare”) was a source of contentious debate in Congress.   The research project that I am undertaking as a fellow in the Center for Health and Nursing Research examines the relationship between health insurance and psychological well-being and stress in American Adults, a relatively understudied topic.  While we do know relatively little about the benefits of health insurance on mental health, empirical research has fairly conclusively demonstrated that health insurance is associated with a number of aspects of physical health and well-being (Baker, Sudano, Albert, Borawski, & Dor 2001; McWilliams, 2009).

Affordable health care is associated with better physical health.  In fact, current and historic data have demonstrated that adults who lack health insurance are at greater risk for death than adults with health insurance (Franks, Clancy & Gold, 1993; Wilper et al., 2009).  This increased risk may be due in part to the fact that individuals without health insurance are less likely to receive routine medical care and preventative care (Hsia et al., 2000; Hadley, 2007; Sudano, et al., 2003; Sudano & Baker, 2003).  Additionally, they are likely to have poorer control of chronic conditions such as Hypertension and Cardiovascular Disease (Havranek et al., 2015; Smolderen et al., 2010), and Diabetes and Kidney Disease (Jurkovitz et al., 2013; Zhang et al., 2008).  Uninsured adults as a population appear to be more likely to receive medical diagnoses when they are more severe and more expensive to treat (Ayanian, Kohler, Abe, & Epstein, 1993; Braveman, Schaaf, Egerter, Bennett, & Schecter, 1994). 

While we do know that individuals with access to affordable health care are physically healthier as a group, this highlights an important area of focus for healthcare administration research—Healthcare Disparities. As we move from January, the month in which we celebrate Martin Luther King Day, and move into African American History month in February, we, as healthcare researchers, need to be cognizant of existing healthcare disparities among socio-demographic minorities (e.g., racial minorities, sexual minorities) in the United States of America (Sudano & Baker, 2006; Williams, 2013).  Historical epidemiological research has found that Hispanic and African American are less likely to have health insurance coverage, and less likely to have regular access to physicians (Hargraves & Hadley, 2003).  There is some evidence that gaps in healthcare disparities have diminished since the implementation of the ACA (Cohen, Martinez, & Zammitti, 2016; Griffith, Evans & Bor, 2017; Okoro, Zhao, Dhingra & Xu, 2015).    It is also hard to tease apart the relationship between minority status, socioeconomic status, and education level as these variables are all highly correlated, and socioeconomic status has been strongly linked to increased mortality and poor health (Braveman, Cubbin, Egerter, Williams, & Pamuk, 2010; Chetty et al., 2016), and multiple forms of minority status may exponentially increase risk for poor health (Zonderman, Mode, Ejiogu, & Evans, 2016).

Thus, we have a complex picture of the relationship between access to healthcare, morbidity and mortality, and socio-demographic characteristics such as race, SES, education and sexual orientation (Adler, Glymour & Fielding, 2016).  As healthcare providers, clinicians, and administrators, and as a collective population, we need to consider paths to balance the disparities, and consider models that can lead to more Americans, regardless of sociodemographic characteristics, are able to receive preventative and primary healthcare..

References

 

Adler, N. E., Glymour, M. M., & Fielding, J. (2016). Addressing social determinants of health and health inequalities. JAMA316, 1641-1642.

Ayanian, J. Z., Kohler, B. A., Abe, T., & Epstein, A. M. (1993). The relation between health insurance coverage and clinical outcomes among women with breast cancer. New England Journal of Medicine329, 326-331.

Baker, D. W., Sudano, J. J., Albert, J. M., Borawski, E. A., & Dor, A. (2001). Lack of health insurance and decline in overall health in late middle age. New England Journal of Medicine345, 1106-1112.

Braveman, P. A., Cubbin, C., Egerter, S., Williams, D. R., & Pamuk, E. (2010). Socioeconomic disparities in health in the United States: What the patterns tell us.  American Journal of Public Health100(S1), S186-S196.

Braveman, P., Schaaf, V. M., Egerter, S., Bennett, T., & Schecter, W. (1994). Insurance-related differences in the risk of ruptured appendix. New England Journal of Medicine331, 444-449.

Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., ... & Cutler, D. (2016). The association between income and life expectancy in the United States, 2001-2014. JAMA315(16), 1750-1766.

Cohen, R.A., Martinez, M.E., & Zammitti, E.P. (2016). Health Insurance Coverage: Early Release of Estimates from the National Health Interview Study, 2015.  Washington, DC: National Center for Health Statistics.  Retrieved from: http://www.cdc.gov/nchs/nhis/releases.htm.

Franks, P., Clancy, C. M., & Gold, M. R. (1993). Health insurance and mortality. JAMA270, 737-741.

Griffith, K., Evans, L., & Bor, J. (2017). The Affordable Care Act reduced socioeconomic disparities in health care access. Health Affairs36, 1503-1510.

Hadley J. (2003). Sicker and poorer? The consequences of being uninsured: A review of the research on the relationship between health insurance, medical care use, health, work, and income. Medical Care Research and Review, 60 (2S), 3S-75S.

Hadley, J. (2007). Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA297, 1073-1084.

Hargraves, J.L. & Hadley, J. (2003). The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care. Health Services Research, 38, 809-829.

Havranek, E. P., Mujahid, M. S., Barr, D. A., Blair, I. V., Cohen, M. S., Cruz-Flores, S., ... & Rosal, M. (2015). Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation132(9), 873-898.

Hsia, J., Kemper, E., Kiefe, C., Zapka, J., Sofaer, S., Pettinger, M., ... & Women's Health Initiative Investigators. (2000). The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative. Preventive Medicine31, 261-270.

Jurkovitz, C. T., Li, S., Norris, K. C., Saab, G., Bomback, A. S., Whaley-Connell, A. T., & McCullough, P. A. (2013). Association between lack of health insurance and risk of death and ESRD: results from the Kidney Early Evaluation Program (KEEP). American Journal of Kidney Diseases61(S4), S24-S32.

McWilliams, J.M. (2009). Health consequences of uninsurance among adults in the United States: recent evidence and implications. The Milbank Quarterly87, 443-494.

Smolderen, K. G., Spertus, J. A., Nallamothu, B. K., Krumholz, H. M., Tang, F., Ross, J. S., ... & Chan, P. S. (2010). Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA, 303, 1392-1400.

Sudano, J. J., & Baker, D. W. (2003). Intermittent lack of health insurance coverage and use of preventive services. American Journal of Public Health93, 130-137.

Sudano, J. J., & Baker, D. W. (2006). Explaining US racial/ethnic disparities in health declines and mortality in late middle age: the roles of socioeconomic status, health behaviors, and health insurance. Social Science & Medicine62, 909-922.

Williams, D. R. (2012). Miles to go before we sleep: Racial inequities in health. Journal of health and social behavior53, 279-295.

Wilper, A. P., Woolhandler, S., Lasser, K. E., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2009). Health insurance and mortality in US adults. American Journal of Public Health99, 2289-2295.

Zhang, X., Geiss, L. S., Cheng, Y. J., Beckles, G. L., Gregg, E. W., & Kahn, H. S. (2008). The missed patient with diabetes: how access to health care affects the detection of diabetes. Diabetes Care31, 1748-1753.

Zonderman, A.B., Mode, N.A., Ejiogu, N., & Evans, M.K. (2016).Race and Poverty Status as a Risk for Overall Mortality in Community-Dwelling Middle-Aged Adults. JAMA Internal Medicine, 176, 1394–1395.

 

 

 

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Emily Moye

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