Appendix E
Recent Studies of the Impacts of Health Insurance for Adults: Summary Table

A table summarizing quasi-experimental studies since 2002 on the impacts of health insurance on health outcomes of adults in the United States is presented in this appendix. The table was originally presented in a literature review commissioned by the Institute of Medicine Committee on Health Insurance Status and Its Consequences in 2008 titled Health Consequences of Uninsurance Among Adults in the United States: An Update, by J. Michael McWilliams, M.D., Ph.D., Harvard Medical School.


Several abbreviations are used in the tables:

  • HRS = Health and Retirement Study

  • MEPS = Medical Expenditure Panel Survey

  • NCHS = National Center for Health Statistics

  • NHIS = National Health Interview Survey

  • NIS = National Inpatient Sample

  • NPHS = National Population Health Survey

  • SEER = Surveillance, Epidemiology, and End Results

  • SSA = Social Security Administration



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Appendix E Recent Studies of the Impacts of Health Insurance for Adults: Summary Table A table summarizing quasi-experimental studies since 2002 on the impacts of health insurance on health outcomes of adults in the United States is presented in this appendix. The table was originally presented in a literature review commissioned by the Institute of Medicine Committee on Health Insurance Status and Its Consequences in 2008 titled Health Con- sequences of Uninsurance Among Adults in the United States: An Update, by J. Michael McWilliams, M.D., Ph.D., Harvard Medical School. Several abbreviations are used in the tables: • HRS = Health and Retirement Study • MEPS = Medical Expenditure Panel Survey • NCHS = National Center for Health Statistics • NHIS = National Health Interview Survey • NIS = National Inpatient Sample • NPHS = National Population Health Survey • SEER = Surveillance, Epidemiology, and End Results • SSA = Social Security Administration 

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 AMERICA’S UNINSURED CRISIS TAbLE E-1 Recent Quasi-Experimental Studies of the Effects of Health Insurance Coverage on Adults’ Health Outcomes, 2002-2008 Study Data Methodological Approach Card et al. (2004) Cross-sectional survey Regression discontinuity The impact of nearly data from the 1992-2001 analysis of general health universal coverage on NHIS; mortality data from status by age health care utilization and NCHS Multiple Cause of health: Evidence from Death files Medicare Card et al. (2007) Cross-sectional state Regression discontinuity Does Medicare save lives? hospital discharge data analysis of mortality by age from California from among acutely ill adults 1992-2002 hospitalized for non-deferrable conditions Decker and Rapaport SEER cancer registry data Difference-in-differences (2002) from 1980-1994 with comparisons of stage of Medicare and inequalities followup mortality data diagnosis and survival for in health outcomes: The white and black women with case of breast cancer breast cancer before and after age 65 Decker (2005) SEER cancer registry data Difference-in-differences Medicare and the health of from 1980-2001 with comparisons of stage of women with breast cancer followup mortality data diagnosis and survival for white, black, and Hispanic women with breast cancer before and after age 65 Decker and Remler (2004) Cross-sectional survey data Difference-in-differences-in- How much might universal from the 1997-1998 NHIS differences comparison of health insurance reduce and the 1996-1997 NPHS general health status by age in socioeconomic disparities the United States and Canada in health?

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199 APPENDIX E Principal  Findings* Limitations Medicare  eligibility  after  age  65  Comparisons  by  prior  insurance  status  or  associated  with  significant  12%  pre-existing  conditions  not  possible  with  reduction  in  sociodemographic  cross-sectional  data;  only  one  self-reported  disparity  in  general  health  status  but  general  health  outcome  assessed;  differential  no  evidence  of  deceleration  in  mortality  changes  in  health  trends  not  assessed;  regression  rates  at  age  65 discontinuity  design  not  suited  for  identification  of  delayed  mortality  effects  in  general  population Medicare  eligibility  after  age  65  Comparisons  by  prior  insurance  status  not  associated  with  abrupt  absolute  possible  with  cross-sectional  data;  alternative  decrease  in  7-day  mortality  of  1%  explanations  for  survival  gains  could  not  be  (20%  relative  reduction)  that  persisted  tested  directly for  at  least  2  years  after  admission Medicare  eligibility  after  age  65  Comparisons  by  prior  insurance  status  not  associated  with  significant  decrease  in  possible;  persistent  racial  and  ethnic  disparities  probability  of  late  detection  for  white  in  outcomes  among  insured  adults  may  have  women  but  not  black  women;  coverage  reduced  differential  effects;  outcomes  assessed  for  estimated  to  increase  5-year  survival  breast  cancer  only rate  for  both  black  and  white  women  diagnosed  with  early  stage  disease,  but  differential  effect  for  black  women  not  significant Medicare  eligibility  after  age  65  Comparisons  by  prior  insurance  status  not  associated  with  absolute  decrease  possible;  persistent  racial  and  ethnic  disparities  of  3.4%  in  probability  of  late  in  outcomes  among  insured  adults  may  have  detection  for  Hispanic  women  and  reduced  differential  effects;  outcomes  assessed  for  1.8%  decrease  for  white  women,  but  breast  cancer  only differential  effect  not  significant;  11%  relative  reduction  in  mortality  risk  after  age  65  did  not  differ  by  race  or  ethnicity Medicare  eligibility  after  age  65  associated  with  a  significant  differential  reduction  of  4.0  percentage  points  (se  =  1.9)  in  probability  of  fair  or  poor  health  for  low-income  U.S.  adults;  socioeconomic  disparity  in  general  health  among  nonelderly  adults  reduced  by  more  than  half Continued

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00 AMERICA’S UNINSURED CRISIS TAbLE E-1 Continued Study Data Methodological Approach Dor et al. (2006) Longitudinal survey data Instrumental variables analysis The effect of private from the 1992-1998 HRS using state-level marginal insurance on the health of tax rates, unemployment older, working age adults: rates, and unionization rates Evidence from the Health as instruments for health and Retirement Study insurance coverage Finkelstein and McKnight Mortality data from Difference-in-differences (2005) NCHS Multiple Cause of comparisons of mortality What did Medicare do Death files before and after 1965 by age (and was it worth it)? (young elderly who became covered by Medicare vs. near-elderly who did not) and by geographic variation in insurance rates prior to 1965 Hadley and Waidmann Longitudinal survey data Instrumental variables analysis (2006) from the 1992-1998 HRS using spouse’s prior union Health insurance status, immigrant status and and health at age 65: years in the Unied States, Implications for medical and involuntary job loss care spending on new as instruments for health Medicare beneficiaries insurance coverage Lichtenberg (2002) Cross-sectional survey data Regression discontinuity The effects of Medicare on from the 1987-1991 NHIS; analyses of disability and health care utilization and vital status data from SSA mortality by age outcomes life tables

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0 APPENDIX E Principal Findings* Limitations Having private insurance at baseline associated with significantly better health scores for a summary index of five general and physical health measures No discernable impact of the introduction of Medicare in 1965 on overall mortality for elderly adults Continuous insurance coverage Validity of results depend on the validity of the associated with significantly fewer instruments used; self-reported health outcomes deaths among the near-elderly prior to age 65 (2.8% absolute decrease in death rate) and significant upward shift in distribution of general health states among those who survived (3.3% and 4.1% absolute increases in probability of excellent and very good health, respectively) 13% relative reduction in bed days Effects not disaggregated by predictors of and 5.1 percentage point decrease in insurance status; comparisons by prior insurance 10-year mortality risk associated with status not possible with cross-sectional data; Medicare eligibility after age 65 potentially spurious results due to data limitations of SSA life tables; formal testing of effects not consistently conducted; alternative explanations not addressed Continued

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0 AMERICA’S UNINSURED CRISIS TAbLE E-1 Continued Study Data Methodological Approach McWilliams et al. (2007) Longitudinal survey data Comparison of health trend Health of previously from the 1992-2004 HRS changes at age 65 by prior uninsured adults after insurance status acquiring Medicare coverage Pauly (2005) Cross-sectional survey data Instrumental variables analysis Effects of insurance from the 1996 MEPS using firm size and marital coverage on use of care status as instruments for and health outcomes for health insurance status non-poor young women Polsky et al. (2006) Longitudinal survey data Comparison of health trend The health effects of from the 1992-2004 HRS changes at age 65 by prior Medicare for the near- insurance status elderly uninsured Volpp et al. (2003) Cross-sectional state and Difference-in-differences Market reform in New national hospital discharge comparisons of mortality rates Jersey and the effect on data from New Jersey, for hospitalized patients with mortality from acute New York, and the NIS acute myocardial infarction myocardial infarction from 1990-1996 in New Jersey and New York before and after state reforms in New Jersey reduced subsidies for hospital care for the uninsured and introduced price competition

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0 APPENDIX E Principal Findings* Limitations Medicare eligibility after age 65 Self-reported health outcomes; subject to bias associated with differentially improved from differential mortality among previously health trends for previously uninsured uninsured or coincidental changes in time-varying with cardiovascular disease or diabetes predictors of health between comparison groups in summary health (p = .006), change in general health (p = .03), mobility (p = .05), agility (p = .003), and adverse cardiovascular outcomes (p = 0.02); differential improvement also significant for depressive symptoms (p = .002) but not summary health (p = 0.17) for previously uninsured without these conditions Associations between insurance Validity of results depend on the validity of the coverage and probability of fair or instruments used; imprecise estimates; only one poor health not significant in either self-reported general health outcome assessed naïve or instrumental variables analyses Medicare eligibility after age Only one self-reported general health outcome 65 associated with significant assessed; subject to bias from differential improvements in health trajectories for mortality among previously uninsured or both previously insured and previously coincidental changes in time-varying predictors uninsured adults; differential increase of health between comparison groups in probability of being in excellent or very good health after age 65 not significant for previously uninsured adults (+1.8%; 95% CI: −2.6,7.0) New Jersey health care reform Subject to bias from coincidental changes in associated with no significant changes state-specific predictors of mortality in insured in mortality for insured patients in and uninsured populations; mortality for only New Jersey relative to New York one conditions assessed; analysis limited to or the nation, but with a significant one state and may not generalize to national differential increase of 3.7 to 5.2 population of uninsured percentage points in mortality rates for uninsured patients in New Jersey Continued

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0 AMERICA’S UNINSURED CRISIS TAbLE E-1 Continued Study Data Methodological Approach Volpp et al. (2005) Cross-sectional state Difference-in-differences The effects of price hospital discharge data comparisons of mortality competition and from New Jersey and New rates for hospitalized patients reduced subsidies for York from 1990-1996 with 6 other acute conditions uncompensated care on in New Jersey and New hospital mortality York before and after state reforms in New Jersey reduced subsidies for hospital care for the uninsured and introduced price competition NOTE: HRS = Health and Retirement Study; MEPS = Medical Expenditure Panel Survey; NCHS = National Center for Health Statistics; NHIS = National Health Interview Survey; NIS = Nationwide Inpatient Sample; NPHS = National Population Health Survey; SEER = Surveillance, Epidemiology, and End Results; SSA = Social Security Administration. *Point estimates, standard errors (se), 95% confidence intervals (CI), or P-values presented as reported in original articles.

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0 APPENDIX E Principal Findings* Limitations New Jersey health care reform Subject to bias from coincidental changes in associated with relative increases in state-specific predictors of mortality in insured mortality for uninsured New Jersey and uninsured populations; analysis limited to patients with congestive heart failure one state and may not generalize to national (p .05) population of uninsured compared to uninsured New York patients; mortality trends similar in New Jersey and New York for patients with other conditions, regardless of insurance status

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