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Trouble Ahead: Lack of Insurance Leads to Poorer Health Among Aging Americans

by William Kanapaux

Geriatric Times July/August 2002 Vol. III Issue 4

Geriatric health care professionals may do well to add an extra item to their list of screening questions for new clients: Have you ever lacked health insurance?

Two reports released in May make a good case for inquiring. An Institute of Medicine (IOM) report shows that working adults who are uninsured for even a year during their adult lives end up suffering greater health problems than do their insured counterparts. And a report by the AARP (formerly known as the American Association of Retired Persons) has found that financial pressures are the greatest threat to health security for Americans over 50.

Although neither report addresses Medicare directly, their implications are that more people will enter the Medicare program with greater health complications as a result of going without coverage at some point during their working years.

The IOM report found that being uninsured is associated with poor clinical outcomes, including:

"Over relatively short time periods -- one to four years -- uninsured adults or adults who lost insurance temporarily are more likely to have diminished health than those who remain continuously insured," Mary Sue Coleman, Ph.D., announced at the release of the IOM report to the media. Coleman is co-chair of the IOM's Committee on the Consequences of Uninsurance.

While the connection between being uninsured and experiencing poor health seems obvious, there exists a widespread misconception that the uninsured receive adequate care. The reality, the IOM report found, is that the uninsured receive substandard acute care and often go without the necessary care to manage chronic conditions.

"Where we see the greatest impact of lacking health insurance is for chronic health problems that go untreated," John Z. Ayanian, M.D., associate professor of medicine and health care policy at Harvard Medical School, said at the press briefing. "Or for screening services, such as screening for cancer, a service that is not typically provided in an emergency department."

Nearly 40 million Americans currently lack health insurance. Of those, 30 million are of working age, between 18 years and 64 years. According to the IOM report, Care Without Coverage: Too Little, Too Late, being uninsured for even a year appears to diminish a person's health. And the consequences of being uninsured are especially profound for adults between 55 and 64 years old.

While coverage doesn't guarantee access to care, it is a primary mechanism for getting care. "The health benefits of insurance coverage can be achieved in full only when health insurance is acquired well before the development of advanced disease," Coleman said at the news conference. "The health benefits of insurance are strongest when coverage is continuous, rather than sporadic."

The AARP report delivered a similar message, offering both good and bad news. According to the report, the health picture for older Americans over the past 20 years has improved. Older Americans are using available services more frequently, are receiving more sophisticated care and are living longer. Fewer older Americans smoke, and more are getting vaccinations and screening tests. Heart disease, stroke and functional limitations in daily living have declined.

But there remain major threats to health security for older Americans, the report said, namely poor health, disability, low income and minority status.

"People age 50 and older are living longer and generally report being healthier than their predecessors," according to Beyond 50: A Report to the Nation on Trends in Health Security. However, health security is out of reach for many older Americans. The number of people lacking health coverage has increased; average health care costs per person have grown; the greater use of prescription medications places a larger out-of-pocket burden on patients without drug coverage; and there are serious deficiencies in health care quality.

The IOM and the AARP are throwing their weight behind their new reports -- which both amassed previously published research findings -- in an effort to better inform lawmakers as they shape health care policy in response to what experts call a growing crisis for U.S. health care.

The IOM report examined the impact of uninsurance on people suffering from cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental illness, traumatic injuries, and heart attacks. The studies examined by the report show that 25% of adults with diabetes who lacked insurance for a year or more went without a checkup for two years, compared to 5% of insured adults with diabetes. Uninsured adults with hypertension or high cholesterol were less likely to monitor their blood pressure or stay on medications.

"For almost every condition, when an uninsured person presents for care, they will present at a higher level of acuity and a later stage of disease," said Edward H. Wagner, M.D., director of the W.A. MacColl Institute for Healthcare Innovation at Group Health Cooperative of Puget Sound in Seattle.

Even short periods of uninsurance result in poor health, said Ayanian. Two-thirds of uninsured working adults lack coverage for a year or longer, resulting in worse outcomes. In particular, adults in their late 40s to early 60s are at the highest risk since they are more likely to have chronic conditions.

A Growing Trend

The AARP report found that a larger proportion of people aged 50 years to 64 years are uninsured now than were in previous years. This trend has affected not only the lowest income groups, but is growing among people at middle and upper income levels.

From 1989 to 1999, the proportion of 50- to 64-year-olds who were uninsured dropped slightly for people in the lowest income category, from 31% to 30%, the report said. However, for the middle income group, the uninsurance rate grew from 12% to 14%, and the highest income group saw its uninsured level rise from 4% to 6%. What is troubling to health policy experts is that this occurred during the economic boom of the 1990s.

Other threats to seniors' health security, Beyond 50 reported, include rising levels of obesity and the number of older adults living with chronic conditions and disabilities.

Obesity is emerging as a significant problem. The rate of obesity for adults 50 years and older nearly doubled between 1982 and 1999. "The epidemic of obesity," the report said, "could cancel out many of the gains achieved in other areas of prevention and treatment of diseases associated with aging." For instance, diabetes has been increasing among older Americans, particularly among 50- to 64-year-olds, which is considered a direct result of the increase in obesity.

The report cited unpublished data from the National Center for Health Statistics that shows the rate of obesity for people age 50 to 64 jumped from 14.4% in 1982 to 26.7% in 1999. The rate for adults 65 to 74 rose from 12.6% to 22.1%.

Disabilities and Limitations

According to the AARP report, the majority of the population 50 years and older is living with at least one chronic condition, disability or functional limitation.

The percentage of adults reporting none of the three problems drops by half once the Medicare threshold is crossed, from 30% of 50- to 64-year-olds to 17% of 65- to 74-year-olds. Conversely, the percentage of older adults reporting all three problems increases dramatically after age 75. Only 8% of seniors aged 65 to 74 reported having all three conditions. That number increased to 19% for the 75 to 84 age group and 44% for those 85 and older.

The AARP report found that average total health care spending (excluding costs for nursing home and other long-term care services) per person age 50 and older increased 310% between 1977 and 1996, twice the rate of inflation. Prescription drugs accounted for a substantial increase, accounting for 15% of out-of-pocket health costs in 1996, compared with 6% in 1997.

In addition to prescription drugs, out-of-pocket spending on long-term care represented the greatest financial risk for older Americans. The report found that caregiving by family and friends provided the cornerstone of long-term care. Informal caregivers age 50 and older make an enormous unpaid contribution to caring for people with disabilities, averaging more than 20 hours per week. More than half these caregivers do so for at least five years.

Both reports are available to the public. The IOM report can be ordered by calling (800) 624-6242 or through the National Academies Web site <www.nap.edu>. The AARP report can be downloaded free at <www.aarp.org/beyond50>.