Care Without Coverage: Too Little, Too Late (2002)

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BOX ES-1 Review of Committee Findings This is a brief overview of the Committee’s specific findings regarding the ef- fects of insurance on the health of American adults. The Committee’s overall con- clusions are presented at the end of the Executive Summary. Prevention and Screening • Uninsured adults are less likely than adults with any kind of health coverage to receive preventive and screening services and to receive them on a timely basis. Health insurance that provides coverage of preventive and screening services is likely to result in greater and more appropriate use of these services. • Health insurance would likely reduce racial and ethnic disparities in the receipt of preventive and screening services. Cancer • Uninsured cancer patients generally are in poorer health and are more likely to die prematurely than persons with insurance, largely because of delayed diagno- sis. This finding is supported by population-based studies of persons with breast, cervical, colorectal, and prostate cancer and melanoma. Chronic Illness • Uninsured adults living with chronic diseases are less likely to receive appropri- ate care to manage their health conditions than are those who have health insur- ance. For the five disease conditions that the Committee examined (diabetes, cardiovascular disease, end-stage renal disease, HIV infection, and mental ill- ness), uninsured patients have consistently worse clinical outcomes than insured patients. • Uninsured adults with diabetes are less likely to receive recommended servic- es. Lacking health insurance for longer periods increases the risk of inadequate care for this condition and can lead to uncontrolled blood sugar levels, which, over time, put diabetics at risk for additional chronic disease and disability. • Uninsured adults with hypertension or high blood cholesterol have diminished access to care, are less likely to be screened, are less likely to take prescription medication if diagnosed, and experience worse health outcomes. • Uninsured patients with end-stage renal disease begin dialysis with more se- vere disease than do those who had insurance before beginning dialysis. • Uninsured adults with HIV infection are less likely to receive highly effective medications that have been shown to improve survival and die sooner than those with coverage. • Adults with health insurance that covers any mental health treatment are more likely to receive mental health services and care consistent with clinical practice guidelines than are those without any health insurance or with insurance that does not cover mental health conditions. 1 

2 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Hospital-Based Care • Uninsured patients who are hospitalized for a range of conditions are more likely to die in the hospital, to receive fewer services when admitted, and to expe- rience substandard care and resultant injury than are insured patients. • Uninsured persons with trauma are less likely to be admitted to the hospital, more likely to receive fewer services when admitted, and are more likely to die than are insured trauma victims. • Uninsured patients with acute cardiovascular disease are less likely to be ad- mitted to a hospital that performs angiography or revascularization procedures, are less likely to receive these diagnostic and treatment procedures, and are more likely to die in the short term. Health insurance reduces the disparity in receipt of these services by members of racial and ethnic minority groups. General Health Status • Relatively short (one- to four-year) longitudinal studies document relatively greater decreases in general health status measures for uninsured adults and for those who lost insurance coverage during the period studied than for those with continuous coverage. • Longitudinal population-based studies of the mortality of uninsured and private- ly insured adults reveal a higher risk of dying prematurely for those who were uninsured at the beginning of the study than for those who initially had private coverage. 

Executive Summary This report, the second in a series of six planned by the Institute of Medicine (IOM) Committee on the Consequences of Uninsurance, examines the relation- ship between being insured or uninsured and the health of American adults. Care Without Coverage: Too Little, Too Late follows the issuance last October of Coverage Matters: Insurance and Health Care, which provided an overview of health insurance in the United States, described the dynamic and frequently unstable nature of coverage, and delineated the extent of uninsurance and the characteristics of Americans who are most likely to be uninsured. Over the next 15 months the Committee will issue reports on family, community, and economic impacts of uninsurance and, last, a report that identifies models and strategies for addressing the problem of uninsurance. Contrary to popular belief, Americans who do not have health insurance are at risk for poorer health as a result of their lack of coverage. In its first report, Coverage Matters: Insurance and Health Care, the Committee presented several popu- lar myths about the lack of health insurance that indicated considerable public misunderstanding about the importance of coverage, which has hampered efforts to advance solutions. In 1999 almost 60 percent of the public believed that uninsured people get the health care they need from doctors and hospitals. The reality is that those without health insurance are much more likely to go without care than are people who have insurance (IOM, 2001a). In this report, the Com- mittee examines whether this reduced access to care results in less appropriate care and poor health consequences. Ascertaining whether health insurance improves health outcomes is critical to shaping public policy about health insurance and the financing of health care more generally. The strongest research studies consistently show that working-age Americans (those between 18 and 65) who do not have health insurance have 3 

4 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE poorer health and die prematurely. The Committee concludes that if these roughly 30 million working-age Americans were to become insured on a continuous basis, their health would be expected to improve. Increasingly, clinical and health services research provides evidence that re- ceiving too little medical care or receiving it too late has harmful effects for those without health insurance. These effects could be ameliorated through the en- hanced access to care that insurance provides. In this report the Committee weighs the evidence of the effect of being uninsured on health-related outcomes for adults and considers the potential benefits of extending health insurance to adults with- out it. In a subsequent report, the Committee will examine comparable studies focused on children. Being uninsured is associated with a variety of worse health-related outcomes, including the following: • less frequent or no use of cancer screening tests resulting in delayed diag- nosis and premature mortality for cancer patients (Ayanian et al., 1993; Roetzheim et al., 1999, 2000a, 2000b; Ferrante et al., 2000; Breen et al., 2001; Perkins et al., 2001); • care that does not meet professionally recommended standards for the management of chronic disease, for example, the failure of persons with diabetes to receive timely eye and foot exams to prevent blindness and amputations (Beckles et al., 1998; Ayanian et al., 2000); • lack of access to and maintenance of appropriate medication regimens for persons with hypertension or HIV infection (W.E. Cunningham et al., 1995, 1999, 2000; Shapiro et al., 1999; Huttin et al., 2000; Goldman et al., 2001); and • fewer diagnostic and treatment services for trauma or heart attacks and an increased risk of death when in the hospital (Haas and Goldman, 1994; Blustein et al., 1995; Canto et al., 1999, 2000; Doyle, 2001). The health benefits of having insurance are even stronger when continuity of coverage is taken into account. Being uninsured for relatively short periods (one to four years) appears to result in a decrease in general health status. When followed over longer periods of time, uninsured adults have been found to be at higher risk of premature death than are persons with private coverage (Lurie et al., 1984, 1986; Franks et al., 1993a; Sorlie et al., 1994; Baker et al., 2001). Additionally, the potential health benefits of having insurance are magnified when vulnerable populations, already at increased risk of worse health, receive coverage. These vulnerable groups include adults who are • chronically ill (especially between the ages of 55 and 64 years), • living with severe mental illness, • members of racial and ethnic minority groups, and • of lower socioeconomic status. 

EXECUTIVE SUMMARY 5 Based on the preponderance of evidence, the Committee concludes that • the health of uninsured adults is worse than it would otherwise be if they were insured, • providing health insurance to uninsured adults would result in improved health, including greater life expectancy, and • increased rates of health insurance coverage would especially im- prove the health of those in the poorest health and most disadvantaged in terms of access to care and thus would likely reduce health disparities among racial and ethnic groups. ASSESSING THE IMPACT OF HEALTH INSURANCE ON HEALTH The Committee reached these conclusions after a review that used explicit criteria to select and evaluate the best-designed research studies investigating the health of working-age adults with and without health insurance. To be selected, studies had to consider (1) an individual’s health insurance status as an independent variable or “predictor,” and (2) the effect of insurance status on one or more health-related outcomes for adults ages 18 through 64. A subsequent report will review the effects of health insurance coverage on children and on pregnant women. Studies that focus primarily on adults 65 years and older were excluded because virtually all in this age group have health insurance coverage through the federal Medicare program.1 This report uses specific definitions of insurance and of the terms of coverage. “Insured adults” means those with general medical and hospitalization insurance, while “uninsured adults” are persons without any health insurance. The Commit- tee has not explicitly considered those who may be inadequately insured (“under- insured”). Although the Committee did not examine studies comparing benefit packages among those with insurance or set out to analyze distinctions among kinds of health insurance, the literature led it to consider some features of health insurance that appear to affect health outcomes. For example, distinctive results from studies that compared those with private and public health insurance point to characteristics such as continuity of coverage and coverage of prescription drugs as important factors. The Committee paid particular attention to studies that exam- ined the length of time participants were uninsured to determine whether and how that factor affected health. 1While Medicare covers hospitalizations, physician, and other outpatient services including reha- bilitative therapies and home health care, it does not cover most outpatient prescription drugs nor does it cover nonrehabilitative long-term care. 

6 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Because most of the evidence comes from studies that are observational rather than experimental, interpreting the evidence about the value of coverage for health outcomes requires application of careful standards of analysis and review. Consequently, analytical adjustments are required to account for potential biases related to variation among study subjects in lengths of time uninsured, types of health insurance coverage, and characteristics of study participants that correlate with health insurance status whose effects can be confused or confounded with those of insurance. Three characteristics of individuals are closely related to health insurance status and, as a result, require analytic adjustment: health status, race and ethnicity, and socioeconomic status. The strongest observational studies use adjustments to separate the effects of these characteristics from those of health insurance coverage. The Committee believes that the research literature likely understates the differences in health outcomes between insured and uninsured adults that can be attributed to health insurance. One of the shortcomings in the literature is a lack of information about the experience of those adults who do not seek care, whether insured or uninsured. Research that relies on administrative or clinical documen- tation of health care use cannot account for the experience of those who do not seek treatment, and uninsured adults are less likely to seek treatment than are insured adults. Thus, studies that rely on health care records to compare groups may actually overstate the utilization of services by uninsured populations. Finding: Health insurance coverage is associated with better health outcomes for adults. It is also associated with having a regular source of care and with greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions such as traumatic injury and heart attacks. The ultimate result is improved health outcomes. Health insurance makes a difference in receipt of services and health out- comes. Direct measures of health examined in studies include self-reported health status, mortality, stage of disease at time of diagnosis, and physiologic measures (e.g., controlled blood pressure in persons with hypertension). Because direct measures of health outcomes are often hard to obtain inexpensively in large-scale studies, intermediate measures of health care processes are commonly used as proxies to assess the effect of health insurance on health. This report examines receipt of recommended services, for example, dilated eye exams annually for persons with diabetes and regular blood pressure checks for those with hyperten- sion, that have been validated by professional guidelines and clinical effectiveness research. 

EXECUTIVE SUMMARY 7 Finding: Health insurance is most likely to improve health outcomes if it is continuous and links people to appropriate health care. When health insurance includes preventive and screening services, pre- scription drugs, and mental health care, it is more strongly associ- ated with the receipt of appropriate care than when insurance does not have these features. Adults without health insurance face serious shortcomings in access to care. The quality and length of life are distinctly different for insured and uninsured populations, with worse health status and shortened lives among uninsured adults. While having health insurance demonstrably increases use of services, more im- portantly, it also facilitates more appropriate use of health care services. In preven- tion and chronic disease management for example, having health insurance greatly increases the likelihood of a regular source of care and of continuity in care, which in turn can improve health outcomes. Finding: Increased health insurance coverage would likely reduce racial and ethnic disparities in the use of appropriate health care services and may also reduce disparities in morbidity and mortality among ethnic groups. Members of different racial and ethnic groups differ in terms of health status, the likelihood of having health insurance, and the care that they receive (Haas and Adler, 2001; IOM, 2001a, 2002; Mills, 2001). Health insurance does not eliminate all disparities among population groups in access to care or remediate all deficits in health status among minority populations. It does, however, facilitate receipt of preventive services, having a regular source of care, and improved quality of care. EFFECTS OF HEALTH INSURANCE ON SPECIFIC HEALTH CONDITIONS In the following discussion of health services and conditions, the evidence reviewed by the Committee is presented as follows: • primary prevention and screening services; • cancer care and outcomes; • chronic disease care and outcomes (including diabetes, cardiovascular dis- ease, end-stage renal disease, HIV infection, and mental illness); • hospital-based care (including trauma care and care for coronary artery disease); • general health outcomes. 

8 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Primary Prevention and Screening Services Finding: Uninsured adults are less likely than adults with any kind of health coverage to receive preventive and screening services and to receive these services on a timely basis. Health insurance that pro- vides more extensive coverage of preventive and screening services is likely to result in greater and more appropriate use of these services. Uninsured adults are less likely than those with health insurance to receive preventive services such as mammograms, clinical breast exams, Pap tests, and colorectal screening (Powell-Griner et al., 1999; Ayanian et al., 2000, Breen et al., 2001). The positive effect of having insurance is more evident with relatively costly services such as mammograms (Zambrana et al., 1999; Cummings et al., 2000). Studies of particular ethnic groups find that health insurance is associated with the increased receipt of preventive services and an increased likelihood of having a regular source of care (Mandelblatt et al., 1999). Generally, insurance benefits are less likely to include preventive and screen- ing services than physician visits for acute care or diagnostic tests for symptomatic conditions. The more extensive the coverage of preventive services, the more likely are health plan enrollees to receive these services (Faulkner and Schauffler, 1997). Yet even if people have health insurance that does not cover preventive services, they are more likely to receive appropriate services than are those with- out any form of health insurance, partly because they are more likely to have a regular source of care or a primary provider. Even after adjustments for age, race, education, and regular source of care, uninsured adults are less likely to receive timely screening for breast, cervical, or colorectal cancer. Once discovered, their cancer is likely to be at a more advanced stage. Cancer Care and Outcomes Finding: Uninsured cancer patients die sooner, on average, than do persons with insurance, largely because of delayed diagnosis. This finding is supported by population-based studies of breast, cervical, colorectal, and prostate cancer and melanoma. Uninsured cancer patients more often fare poorly than do patients with coverage. A relatively advanced, often fatal, late stage of disease at the time of diagnosis is more common among persons without insurance coverage, reflecting their reduced use of timely screening services. Uninsured persons with breast, colorectal, or prostate cancer are more likely to die prematurely from their disease than are patients with private health insurance. For example, uninsured women with breast cancer have a risk of dying that is between 30 and 50 percent higher 

EXECUTIVE SUMMARY 9 than the risk for women with private health insurance (Ayanian et al., 1993; Lee- Feldstein et al., 2000; Roetzheim et al., 2000a), and uninsured patients with colorectal cancer are about 50 percent more likely to die than are patients with private coverage, even when the cancer is diagnosed at similar stages (Roetzheim et al., 2000b). This evidence comes from research using area or statewide cancer registries. Uninsured adults with cancer might experience differences in treatment. For example, uninsured women with breast cancer are less likely than privately insured women to receive breast-conserving surgery (Roetzheim et al., 2000a). It should be noted, however, that disparities in treatment persist among racial and ethnic groups even if all have insurance (IOM, 2002). Chronic Disease Care and Outcomes Finding: Uninsured adults living with chronic diseases are less likely to receive appropriate care to manage their health conditions than are those who have health insurance. For all five disease conditions (in addition to cancer) that the Committee examined (diabetes, cardiovascular disease, end-stage renal disease, HIV infection and mental illness), uninsured patients have consistently worse clinical outcomes than do insured patients. For persons living with a chronic illness, health insurance may be most important in enhancing opportunities to acquire a regular source of care and receive appropriate management of their condition. Identifying chronic condi- tions early and providing professionally recommended, cost-effective interven- tions on an ongoing and coordinated basis can improve health outcomes. Yet uninsured adults with chronic conditions are less likely to have a usual source of care or regular check-ups than are chronically ill persons with coverage (Ayanian et al., 2000; Fish-Parcham, 2001). Diabetes Uninsured persons with diabetes are less likely to receive recommended services. Lacking health insurance for longer periods increases the risk of inad- equate care for this condition and can lead to uncontrolled blood sugar levels, which, over time, put diabetics at risk for additional chronic disease and disability. Despite the demanding and costly care regimen that persons with diabetes face, adults with diabetes are almost as likely to be uninsured as adults without this disease (12 percent are uninsured compared to the general population uninsured rate of 15 percent [Harris, 1999].) Uninsured adults with diabetes are less likely to receive the recommended professional standard of care than those with health insurance. For example, they are less likely to receive regular foot or dilated eye exams that are important in the 

10 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE prevention of foot ulcers and blindness. Twenty-five percent of adults with diabe- tes who were uninsured for a year or more went without a checkup within the past two years, compared to 7 percent of diabetics who were uninsured for less than a year and 5 percent of diabetics with health insurance (Beckles et al., 1998; Ayanian et al., 2000). Cardiovascular Disease Uninsured adults with hypertension or high cholesterol have diminished access to care, are less likely to be screened, are less likely to take prescription medication if diagnosed, and experience worse health. According to analyses of national health survey data, 19 percent of uninsured adults with heart disease and 13 percent with hypertension lack a usual source of care, compared to 8 and 4 percent, respectively, of their insured counterparts (Fish-Parcham, 2001). Uninsured adults have less frequent monitoring of blood pressure once they are diagnosed with hypertension and are less likely to stay on drug therapy than are insured adults who have hypertension (Huttin et al., 2000; Fish-Parcham, 2001). Loss of insurance coverage disrupts therapeutic relationships and worsens blood pressure control (Lurie et al., 1984, 1986). Deficits in care for uninsured adults with hypertension or high cholesterol place them at risk of complications and deterioration of their condition. For example, patients admitted to emergency departments with severe uncontrolled hypertension were more likely to be unin- sured than socio-demographically similar patients with any insurance (Shea et al., 1992a, 1992b). End-Stage Renal Disease Uninsured patients have more severe renal failure when they begin dialysis than insured patients (Kausz et al., 2000). The clinical goals for patients with kidney disease are to slow the progression of renal failure, manage complications, and prevent or manage coexisting disease effectively. Uninsured patients are less likely than insured patients to have received treatment for related anemia before initiating dialysis, and their health status is already compromised by a greater likelihood of more severe anemia (Obrador et al., 1999). The virtually universal qualification of end-stage renal disease (ESRD) pa- tients for Medicare once dialysis or transplantation becomes necessary erases pre- viously existing gender and racial or ethnic disparities in access to hospital-based care for ESRD patients with heart disease (Daumit et al., 1999, 2000). Human Immunodeficiency Virus Infection Uninsured adults, once diagnosed with HIV, face greater delays in accessing appropriate care than those with health insurance and are more likely to forgo 

EXECUTIVE SUMMARY 11 needed care. Persons without health insurance have been shown to wait more than three months after diagnosis to have their first office visit and to wait an average of four months longer than privately insured patients to receive newer drug therapies (Turner et al., 2000). Furthermore, the uninsured with HIV are less likely to be able to maintain a recommended drug regimen over time (Cunningham et al., 2000). Uninsured adults with HIV infection are less likely to receive highly effective medications that have become the standard of treatment within the past five years and been shown to improve survival (Carpenter et al., 1996, 1998; Goldman et al., 2001). Having health insurance of any kind has been found to reduce mortality in HIV-infected adults by 71–85 percent over a six-month period, with the greater reduction found more recently when effective drug therapies were in more wide- spread use (Goldman et al., 2001). Mental Illness Adults with health insurance that covers any mental health treatment are more likely to receive mental health services and care consistent with clinical practice guidelines than are those without any health insurance or with insurance that does not cover mental health conditions. Mental illness represents a major but often underestimated source of disability and is equivalent to heart disease and cancer in terms of its impact. Depression and anxiety disorders are often treatable in the general medical sector and primarily require outpatient services. Severe mental illnesses (schizophrenia, other psycho- ses, and bipolar depression) require the attention of specialty mental health profes- sionals and may require more extensive services (e.g., inpatient services, partial or day hospitalization). Receipt of appropriate care has been associated with improved functional outcomes for depression and anxiety disorders, yet the uninsured are less likely to receive this degree of care. Patients without health insurance for mental health visits who were diagnosed with depression, panic disorder, or generalized anxiety disorder were less likely to receive mental health services (Druss and Rosenheck, 1998; Cooper-Patrick et al., 1999). When they did receive care, it was less likely to be appropriate (concordant with professional practice guidelines) (Wang et al., 2000; Young et al., 2001). Uninsured adults with severe mental illnesses also receive less appropriate care or medications and experience delays in receiving services until they gain public insurance coverage (Rabinowitz et al., 1998, 2001; McAlpine and Mechanic, 2000). Even when health insurance does not specifically cover mental health ser- vices, having it increases the likelihood that someone with depression or anxiety will receive some care for the condition. Persons with a severe mental illness such as schizophrenia or bipolar disorder face difficulties in obtaining and then keeping health insurance after diagnosis. When they do have health insurance, especially public insurance (Medicare or Medicaid), they are more likely to receive specialty 

12 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE mental health services than are severely ill persons without any health insurance or even patients with private insurance. Hospital-Based Care Finding: Uninsured patients who are hospitalized for a range of conditions are more likely to die in the hospital, to receive fewer services, and, when admitted, are more likely to experience substan- dard care and resultant injury than are insured patients. Poorer health status for uninsured adults when they are hospitalized is com- pounded by their experiences as inpatients. Being uninsured is associated with the receipt of fewer needed services, worse quality care, and greater risk of dying in the hospital or shortly after discharge (Hadley et al., 1991; Burstin et al., 1992; Haas and Goldman, 1994; Blustein et al., 1995; Doyle, 2001). Being uninsured and not having a regular source of care are also associated with delays in seeking care from the emergency department for a variety of conditions, delays that may compromise outcomes (e.g., rupture in acute appendicitis) (Braveman et al., 1994). Because most hospital-based studies are biased by the inclusion of self-selected patients who “show up” for care, the Committee decided to focus on two condi- tions—traumatic injuries and acute cardiac events—for which most people receive hospital care whether or not they are insured. Traumatic Injuries Uninsured persons with traumatic injuries are less likely to be admitted to the hospital, receive fewer services when admitted, and are more likely to die than are insured trauma victims. Provider response to traumatic injury can be influenced by insurance status. In one statewide study of uninsured auto accident victims, uninsured patients were found to receive less care and had a 37 percent higher mortality rate than did privately insured accident victims (Doyle, 2001). Another statewide study showed while uninsured trauma patients were as likely to receive intensive care unit services as privately insured patients, they were less likely to undergo operative procedures or receive physical therapy (Haas and Goldman, 1994). Acute Cardiovascular Disease Uninsured patients with acute cardiovascular disease are less likely to be admitted to a hospital that performs angiography or revascularization procedures, are less likely to receive these diagnostic and treatment procedures, and are more likely to die in the short term. Health insurance reduces the disparity in receipt of these services for women relative to men and for members of racial and ethnic minority groups (Carlisle et al., 1997; Daumit et al., 1999, 2000). 

EXECUTIVE SUMMARY 13 Insurance status influences the receipt of hospital-based treatments for cardio- vascular disease (specifically, coronary artery disease). Uninsured patients hospital- ized for acute myocardial infarction (heart attack) experience a greater risk of dying during their hospital stay or shortly thereafter than do patients with private insurance (Young and Cohen, 1991; Blustein et al., 1995; Canto et al., 2000). The choice of hospital itself has significant effects on diagnosis, treatment, and health-related outcomes. Uninsured patients are less likely to be admitted to a hospital that performs angiography or cardiac revascularization (Leape et al., 1999) and are less likely to receive these diagnostic and treatment procedures regardless of hospital facilities (Canto et al., 1999). Insurance status has also been shown to influence access to transfers for revascularization (Blustein et al., 1995). GENERAL HEALTH OUTCOMES An uninsured adult’s experiences with ambulatory and hospital care influence his or her health status in important ways over the short term and may lead to a premature death. Health Status Finding: Relatively short (one- to four-year) longitudinal studies document decreases in general health status measures for uninsured adults and for those who lost insurance coverage compared to per- sons with continuous coverage. Like those with chronic health conditions, adults in late middle age are more likely to experience declines in function and health status if they lack or lose health insurance coverage (Baker et al., 2001). Changes in health status might include worsening control of blood pressure, decreased ability to walk or climb stairs, or decline of general self-perceived wellness and functioning. The effect of being uninsured on self-reported health measures is greater for lower-income persons (Franks et al., 1993b). Mortality Finding: Longitudinal population-based studies of the mortality of uninsured and privately insured adults reveal a higher risk of dying for those who were uninsured at the beginning of the study than for those who initially had private coverage. Longer-term population-based studies (from 5 to 17 years) find a 25 percent higher risk of dying for adults who were uninsured at the beginning of the study (Franks et al., 1993a; Sorlie et al., 1994). These analyses of overall mortality are corroborated by the mortality experience of insured and uninsured patients with 

14 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE heart attack, cancer, traumatic injury, and HIV infection (Blustein et al., 1995; Canto et al., 2000; Ayanian et al., 1993; Roetzheim et al., 2000a; Doyle, 2001; Goldman et al., 2001). THE DIFFERENCE COVERAGE COULD MAKE TO THE HEALTH OF UNINSURED ADULTS Particular groups of uninsured adults are more likely to experience poor health or barriers to care and thus can be expected to benefit more from gaining health insurance. These groups include uninsured adults who are chronically ill, persons with severe mental illness, members of some racial and ethnic minority groups, and persons with lower socioeconomic status. Many of the uninsured belong to one or more of these higher-risk groups. The Committee bases the following summary conclusions on the substantial consistency of results among the methodologically strongest observational studies in its review and the coherence of these results with the behavioral research that informs the Committee’s conceptual model of mechanisms by which health insur- ance affects health outcomes: • Having health insurance is associated with better health outcomes for adults and with their receipt of appropriate care across a range of preventive, chronic, and acute care services. Adults without health in- surance coverage die sooner and experience greater declines in health status over time than do adults with continuous coverage. • Adults with chronic conditions and those in late middle age stand to benefit the most from health insurance coverage in terms of im- proved health outcomes because of their high probability of needing health care services. • Population groups that most often lack stable health insurance coverage and that have worse health status, including racial and ethnic minorities and lower-income adults, would benefit most from increased health insurance coverage. Increased coverage would likely reduce some of the racial and ethnic disparities in the utilization of appropriate health care services and may also reduce disparities in morbidity and mortality among ethnic groups. • Health insurance that affords access to providers and includes preventive and screening services, outpatient prescription drugs, and specialty mental health care is more likely to facilitate the receipt of appropriate care. • Broad-based health insurance strategies across the entire unin- sured population would be more likely to produce these benefits than would “rescue” programs aimed only at the seriously ill. What differences in health care utilization and outcomes would health insur- 

EXECUTIVE SUMMARY 15 ance make if the uninsured were provided with coverage? Despite the scarcity of experiments testing the impacts of providing health insurance to the previously uninsured, the Committee believes that the powerful and consistent observational evidence across a wide variety of populations and health conditions, corroborated by the few experimental and quasi-experimental studies that have been con- ducted, provides a reasonable basis for answering this question. The key lies in the role health insurance can play in facilitating access to care and the timely and appropriate use of services. In addition, if uninsured adults were insured on a continuous basis, their health status would likely be better than it would be otherwise and their risk of dying prematurely would be reduced. The survival benefits derived from insurance coverage, however, can be achieved in full only when health insurance is acquired well before the development of ad- vanced disease. The problem of later diagnosis and higher mortality among unin- sured women with breast cancer, for example, cannot be solved by insuring women once their disease is diagnosed (Perkins et al., 2001). Finally, the evidence presented accounts only for some of the benefits and advantages that health insurance provides. Financial risk reduction and economic security are major benefits that accrue to everyone with coverage, whether or not they use it (IOM, 2001a). Patient satisfaction and the sense of being valued when professional and caring attention is provided in painful, stressful, or frightening circumstances are genuine, desirable outcomes. These qualities are more likely to be found in health care settings and healing relationships where one is confident of good access to health care providers’ time and resources. Adults without health insurance are less likely to feel deserving of a physician’s attention when they seek care, and indeed, uninsured adults are less likely to seek needed care than are those with health insurance. Financial security and stability, peace of mind, alleviation of pain and suffering, improved physical function, disabilities avoided or delayed, and gains in life expectancy constitute an array of health insurance benefits that accrue to members of our society who have health insurance. For many of the 40 million uninsured Americans, these benefits remain out of reach.