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Fronstin P. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1999 Current Population Survey. Washington, DC: Employee Benefit Research Institute; 2000:1-26.
Weissman JS, Epstein AM. Falling Through the Safety Net: Insurance Status and Access to Health Care. Baltimore, Md: Johns Hopkins University Press; 1994.
Rowland D, Feder J, Keenan PS. Uninsured in America: the causes and consequences. In: Altman SH, Reinhardt UE, Shields AE, eds. The Future US Healthcare System: Who Will Care for the Poor and Uninsured? Chicago, Ill: Health Administration Press; 1998:25-44.
American College of Physicians-American Society of Internal Medicine.  No Health Insurance? It's Enough to Make You Sick. Philadelphia, Pa: American College of Physicians-American Society of Internal Medicine; 2000.
Hafner-Eaton C. Physician utilization disparities between the uninsured and insured: comparisons of the chronically ill, acutely ill, and well nonelderly population.  JAMA.1993;269:787-792.Google Scholar
Franks P, Clancy CM, Gold MR, Nutting PA. Health insurance and subjective health status: data from the 1987 National Medical Expenditure Survey.  Am J Public Health.1993;83:1295-1299.Google Scholar
Hahn B, Flood AB. No insurance, public insurance, and private insurance: do these options contribute to differences in general health?  J Health Care Poor Underserved.1995;6:41-59.Google Scholar
Centers for Disease Control and Prevention.  Self-assessed health status and selected behavioral risk factors among persons with and without health-care coverage: United States, 1994-1995.  MMWR Morb Mortal Wkly Rep.1998;47:176-180.Google Scholar
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.Google Scholar
Baker DW, Shapiro MF, Schur CL. Health insurance and access to care for symptomatic conditions.  Arch Intern Med.2000;160:1269-1274.Google Scholar
Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance.  JAMA.1988;259:2872-2874.Google Scholar
Centers for Disease Control and Prevention.  Health insurance coverage and receipt of preventive health services: United States, 1993.  MMWR Morb Mortal Wkly Rep.1995;44:219-225.Google Scholar
Himmelstein DU, Woolhandler S. Care denied: US residents who are unable to obtain needed medical services.  Am J Public Health.1995;85:341-344.Google Scholar
Ford ES, Will JC, Ford MAD, Mokdad AH. Health insurance status and cardiovascular disease risk factors among 50-64-year-old women: findings from the Third National Health and Nutrition Examination Survey.  J Womens Health.1998;7:997-1006.Google Scholar
Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer.  N Engl J Med.1993;329:326-331.Google Scholar
Roetzheim RG, Pal N, Tennant C.  et al.  Effects of health insurance and race on early detection of cancer.  J Natl Cancer Inst.1999;91:1409-1415.Google Scholar
Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.  JAMA.1992;268:2388-2394.Google Scholar
Franks P, Clancy CM, Gold MR. Health insurance and mortality: evidence from a national cohort.  JAMA.1993;270:737-741.Google Scholar
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.Google Scholar
Cunningham PJ, Grossman JM, St Peter RF, Lesser CS. Managed care and physicians' provision of charity care.  JAMA.1999;282:1087-1092.Google Scholar
Hawkins DR, Rosenbaum S. The challenges facing health centers in a changing healthcare system. In: Altman SH, Reinhardt UE, Shields AE, eds. The Future US Healthcare System: Who Will Care for the Poor and Uninsured? Chicago, Ill: Health Administration Press; 1998:99-122.
Gage LS. The future of safety-net hospitals. In: Altman SH, Reinhardt UE, Shields AE, eds. The Future US Healthcare System: Who Will Care for the Poor and Uninsured? Chicago, Ill: Health Administration Press; 1998:123-149.
Cunningham PJ. Pressures on safety net access: the level of managed care penetration and uninsurance rate in a community.  Health Serv Res.1999;34:255-270.Google Scholar
United States General Accounting Office.  Health Care Access: Programs for Underserved Populations Could Be Improved. Washington, DC: US General Accounting Office; 2000.
Jensen GA. The dynamics of health insurance among the near elderly.  Med Care.1992;30:598-614.Google Scholar
Swartz K, Marcotte J, McBride TD. Personal characteristics and spells without health insurance.  Inquiry.1993;30:64-76.Google Scholar
McBride TD. Uninsured spells of the poor: prevalence and duration.  Health Care Financ Rev.1997;19:145-160.Google Scholar
 State-specific prevalence of lapses in health-care-insurance coverage: United States, 1995.  MMWR Morb Mortal Wkly Rep.1998;47:73-77.Google Scholar
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.Google Scholar
Burstin HR, Swartz K, O'Neil AC, Orav EJ, Brennan TA. The effect of change of health insurance on access to care.  Inquiry.1998;35:389-397.Google Scholar
Schoen C, DesRoches C. Uninsured and unstably insured: the importance of continuous insurance coverage.  Health Serv Res.2000;35:187-206.Google Scholar
Brechner RJ, Cowie CC, Howie LJ, Herman WH, Will JC, Harris MI. Ophthalmic examination among adults with diagnosed diabetes mellitus.  JAMA.1993;270:1714-1718.Google Scholar
Beckles GLA, Engelgau MM, Venkat Narayan KM, Herman WH, Aubert RE, Williamson DF. Population-based assessment of the level of care among adults with diabetes in the US.  Diabetes Care.1998;21:1432-1438.Google Scholar
Moy E, Bartman BA, Weir MR. Access to hypertensive care: effects of income, insurance, and source of care.  Arch Intern Med.1995;155:1497-1502.Google Scholar
Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population.  N Engl J Med.1992;327:776-781.Google Scholar
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.  The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.  Arch Intern Med.1997;157:2413-2446.Google Scholar
Schroeder SA. The medically uninsured: will they always be with us?  N Engl J Med.1996;334:1130-1133.Google Scholar
Blendon RJ, Young JT, DesRoches CM. The uninsured, the working uninsured, and the public.  Health Aff (Millwood).1999;18:203-211.Google Scholar
Powell-Griner E, Anderson JE, Murphy W. State-and sex-specific prevalence of selected characteristics: Behavioral Risk Factor Surveillance System, 1994 and 1995.  Mor Mortal Wkly Rep CDC Surveill Summ.1997;46(SS-3):1-31.Google Scholar
Centers for Disease Control and Prevention.  Behavioral Risk Factor Surveillance System Web site. Available at: http://www.cdc.gov/nccdphp/brfss. Accessed September 22, 2000.
Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess deaths from nine chronic diseases in the United States, 1986.  JAMA.1990;264:2654-2659.Google Scholar
McGinnis JM, Foege WH. Actual causes of death in the United States.  JAMA.1993;270:2207-2212.Google Scholar
US Preventive Services Task Force.  Guide to Clinical Preventive Services. Baltimore, Md: Williams & Wilkins; 1996.
Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomised study of screening for colorectal cancer with faecal-occult-blood test.  Lancet.1996;348:1467-1471.Google Scholar
Hardcastle JD, Chamberlain JO, Robinson MHE.  et al.  Randomised controlled trial of faecal-occult-blood screening for colorectal cancer.  Lancet.1996;348:1472-1477.Google Scholar
Mandel JS, Church TR, Ederer F, Bond JH. Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood.  J Natl Cancer Inst.1999;91:434-437.Google Scholar
Selby JV, Friedman GD, Quesenberry Jr CP, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer.  N Engl J Med.1992;326:653-657.Google Scholar
Byers T, Levin B, Rothenberger D.  et al.  American Cancer Society guidelines for screening and surveillance for early detection of colorectal polyps and cancer: update 1997.  CA Cancer J Clin.1997;47:154-160.Google Scholar
Winawer SJ, Fletcher RH, Miller L.  et al.  Colorectal cancer screening: clinical guidelines and rationale.  Gastroenterology.1997;112:594-642.Google Scholar
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.  Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II).  JAMA.1993;269:3015-3023.Google Scholar
American College of Physicians.  Guidelines for using serum cholesterol, high-density lipoprotein cholesterol, and triglyceride levels as screening tests for preventing coronary heart disease in adults: part 1.  Ann Intern Med.1996;124:515-517.Google Scholar
Garber AM, Browner WS, Hulley SB. Cholesterol screening in asymptomatic adults, revisited: part 2.  Ann Intern Med.1996;124:518-531.Google Scholar
The Smoking Cessation Clinical Practice Panel and Staff.  The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline.  JAMA.1996;275:1270-1280.Google Scholar
American Diabetes Association.  Standards of medical care for patients with diabetes mellitus.  Diabetes Care.1998;21(suppl 1):S23-S31.Google Scholar
American Diabetes Association.  Immunization and the prevention of influenza and pneumococcal disease in people with diabetes.  Diabetes Care.2000;21:109-111.Google Scholar
Vijan S, Hofer TP, Hayward RA. Cost-utility analysis of screening intervals for diabetic retinopathy in patients with type 2 diabetes mellitus.  JAMA.2000;283:889-896.Google Scholar
Rubin DB, Schenker N. Multiple imputation in health-care databases: an overview and some applications.  Stat Med.1991;10:585-598.Google Scholar
Heitjan DF. What can be done about missing data? approaches to imputation.  Am J Public Health.1997;98:548-550.Google Scholar
Schafer JL. Multiple imputation: a primer.  Stat Methods Med Res.1999;8:3-15.Google Scholar
Schafer JL. Analysis of Incomplete Multivariate Data. New York, NY: Chapman & Hall; 1997.
Little RJA. Direct standardization: a tool for teaching linear models for unbalanced data.  Am Stat.1982;36:38-43.Google Scholar
Leape LL, Hilborne LH, Bell R, Kamberg C, Brook RH. Underuse of cardiac procedures: do women, ethnic minorities, and the uninsured fail to receive needed revascularization?  Ann Intern Med.1999;130:183-192.Google Scholar
Frane J. SUDAAN: Professional Software for Survey Data Analysis. Research Triangle Park, NC: Research Triangle Institute; 1989.
LaVange LM, Stearns SC, Lafata JE, Koch GG, Shah BV. Innovative strategies using SUDAAN for analysis of health surveys with complex samples.  Stat Methods Med Res.1996;5:311-329.Google Scholar
Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York, NY: John Wiley & Sons; 1987.
Donelan K, Blendon RJ, Hill CA.  et al.  Whatever happened to the health insurance crisis in the United States? voices from a national survey.  JAMA.1996;276:1346-1350.Google Scholar
Marks JS, Lee NC, Lawson HW, Henson R, Bobo JK, Kaeser MK. Implementing recommendations for the early detection of breast and cervical cancer among low-income women.  MMWR Morb Mortal Wkly Rep.2000;49(RR02):35-55.Google Scholar
Centers for Disease Control and Prevention.  Self-reported use of mammography and insurance status among women aged greater than or equal to 40 years: United States, 1991-1992 and 1996-1997.  MMWR Morb Mortal Wkly Rep.1998;47:825-830.Google Scholar
US Department of Health and Human Services.  Healthy People 2010 Web site. Available at: http://www.health.gov/healthypeople. Accessed September 22, 2000.
Krebs-Carter M, Holahan J. State Strategies for Covering Uninsured Adults. Washington, DC: The Urban Institute; 2000.
Schoen C, Lyons B, Rowland D, Davis K, Puleo E. Insurance matters for low-income adults: results from a five-state survey.  Health Aff (Millwood).1997;16:163-171.Google Scholar
Davis K, Schoen C. Incremental health insurance coverage: building on the current system. In: Altman SH, Reinhardt UE, Shields AE, eds. The Future US Healthcare System: Who Will Care for the Poor and Uninsured? Chicago, Ill: Health Administration Press; 1998:247-263.
Short PF, Klerman JA. Targeting Long- and Short-Term Gaps in Health Insurance. New York, NY: Commonwealth Fund; 1998.
Schoen C, Puleo E. Low-income working families at risk: uninsured and underserved.  J Urban Health.1998;75:30-49.Google Scholar
Blumenthal D. Health care reform at the close of the 20th century.  N Engl J Med.1999;340:1916-1920.Google Scholar
Ku L, Coughlin TA. Sliding-scale premium health insurance programs: four state's experiences.  Inquiry.1999;36:471-480.Google Scholar
Shea S, Stein AD, Lantigua R, Basch CE. Reliability of the Behavioral Risk Factor Survey in a triethnic population.  Am J Epidemiol.1991;133:489-500.Google Scholar
Stein AD, Lederman RI, Shea S. The Behavioral Risk Factor Surveillance System questionnaire: its reliability in a statewide sample.  Am J Public Health.1993;83:1768-1772.Google Scholar
Stein AD, Courval JM, Lederman RI, Shea S. Reproducibility of responses to telephone interviews: demographic predictors of discordance to risk factor status.  Am J Epidemiol.1995;141:1097-1106.Google Scholar
Bowlin SJ, Morrill BD, Nafziger AN, Lewis C, Pearson TA. Reliability and changes in validity of self-reported cardiovascular disease risk factors using dual response: The Behavioral Risk Factor Survey.  J Clin Epidemiol.1996;49:511-517.Google Scholar
Bowlin SJ, Morrill BD, Nafziger AN, Jenkins PL, Lewis C, Pearson TA. Validity of cardiovascular disease risk factors assessed by telephone survey: the Behavioral Risk Factor Survey.  J Clin Epidemiol.1993;46:561-571.Google Scholar
Degnan D, Harris R, Ranney J.  et al.  Measuring the use of mammography: two methods compared.  Am J Public Health.1992;82:1386-1388.Google Scholar
Selden TM, Banthin JS, Cohen JW. Waiting in the wings: eligibility and enrollment in the State Children's Health Insurance Program.  Health Aff (Millwood).1999;18:126-133.Google Scholar
Original Contribution
October 25, 2000

Unmet Health Needs of Uninsured Adults in the United States

Author Affiliations

Author Affiliations: Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital (Drs Ayanian and Schneider), Department of Health Care Policy, Harvard Medical School (Drs Ayanian, Weissman, and Zaslavsky), Institute for Health Policy, Massachusetts General Hospital (Dr Weissman), and Department of Health Policy and Management, Harvard School of Public Health (Dr Schneider), Boston, Mass; and the American College of Physicians-American Society of Internal Medicine (Mr Ginsburg), Washington, DC.

JAMA. 2000;284(16):2061-2069. doi:10.1001/jama.284.16.2061

Context In 1998, 33 million US adults aged 18 to 64 years lacked health insurance. Determining the unmet health needs of this population may aid efforts to improve access to care.

Objective To compare nationally representative estimates of the unmet health needs of uninsured and insured adults, particularly among persons with major health risks.

Design and Setting Random household telephone survey conducted in all 50 states and the District of Columbia through the Behavioral Risk Factor Surveillance System.

Participants A total of 105,764 adults aged 18 to 64 years in 1997 and 117,364 in 1998, classified as long-term (≥1 year) uninsured (9.7%), short-term (<1 year) uninsured (4.3%), or insured (86.0%).

Main Outcome Measures Adjusted proportions of participants who could not see a physician when needed due to cost in the past year, had not had a routine checkup within 2 years, and had not received clinically indicated preventive services, compared by insurance status.

Results Long-term– and short-term–uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost (26.8%, 21.7%, and 8.2%, respectively), especially among those in poor health (69.1%, 51.9%, and 21.8%) or fair health (48.8%, 42.4%, and 15.7%) (P<.001). Long-term–uninsured adults in general were much more likely than short-term–uninsured and insured adults not to have had a routine checkup in the last 2 years (42.8%, 22.3%, and 17.8%, respectively) and among smokers, obese individuals, binge drinkers, and people with hypertension, elevated cholesterol, diabetes, or human immunodeficiency virus risk factors (P<.001). Deficits in cancer screening, cardiovascular risk reduction, and diabetes care were most pronounced among long-term–uninsured adults.

Conclusions In our study, long-term–uninsured adults reported much greater unmet health needs than insured adults. Providing insurance to improve access to care for long-term–uninsured adults, particularly those with major health risks, could have substantial clinical benefits.