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February 10, 1993

Physician Utilization Disparities Between the Uninsured and Insured: Comparisons of the Chronically III, Acutely III, and Well Nonelderly Populations

JAMA. 1993;269(6):787-792. doi:10.1001/jama.1993.03500060087037

Background.  —This study examines the associations between lack of health insurance coverage and physician utilization for the chronically ill, acutely ill, and well nonelderly populations in the United States.

Methods.  —Cross-sectional data from the 1989 National Health Interview Survey, conducted by the National Center for Health Statistics, were analyzed for the nonelderly population using a correlational, two-group design (N=102 055). Analytic models, using multiple logistic regression, were tested to predict the odds and likelihood of physician utilization for the uninsured and insured in the three subpopulations (ie, chronically ill, acutely ill, and well), controlling for health status, number of conditions, and geographic, sociodemographic, and economic factors. Disparities in utilization were then calculated between the uninsured and insured for each subpopulation.

Results.  —The nonelderly uninsured were consistently less likely than the insured to have received any health care within 12 months. Moreover, there were differential effects of being uninsured on utilization depending on whether an individual was chronically ill, acutely ill, or well. Whereas chronically ill and well uninsured persons were half as likely to have seen a physician as their insured counterparts (odds ratio, 0.50), acutely ill uninsured persons were almost two thirds as likely to receive physician care (odds ratio, 0.62). Thus, the disparity in physician utilization between the uninsured and insured was larger for the chronically ill and well than for the acutely ill; uninsured acutely ill were less likely to go without care. Of the three populations, those in the well population had average disparities with the largest magnitude (40%), compared with disparities of the chronically ill (20%) and acutely ill (10%).

Conclusions.  —These disparities represent large inequities in utilization of care by the uninsured, particularly for the chronically ill and well. Whether these disparities result from lower access or individual choice cannot be determined from this study. When viewed in light of other studies examining the impact of utilization on health status, these results provide support for the development of comprehensive health insurance packages with universal coverage and better inclusion of chronic and preventive care models in benefit packages.(JAMA. 1993;269:787-792)