ABLEnews Extra The following information regarding health insurance coverage is provided courtesy of Dr. Gary Greenberg on OCC-ENV-MED. [The following file may be freq'd as HIN1993.* from 1:109/909 and other BBS's that carry the ABLEFiles Distribution Network (AFDN) and--for about one week-- ftp'd from FTP.FIDONET.ORG on the Internet. Please allow a few days for processing.] Health Insurance Coverage and Receipt of Preventive Health Services-- United States, 1993 In 1992, an estimated 38.5 million U.S. residents aged less than 65 years did not have health insurance (1). Efforts by states to expand health-care coverage will require surveillance for and state-specific information about coverage for acute care and the receipt of preventive services. This report summarizes state-specific and aggregated data from the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding the status of health insurance coverage and the receipt of preventive health services among adults aged 18-64 years. In addition, findings from the analysis of supplemental questions added to the BRFSS in Minnesota are included that address health-care utilization, source of health-care coverage, and coverage of children. In 1993, the District of Columbia and all states except Wyoming participated in the BRFSS, a population-based, random-digit-dialed telephone survey of adults aged greater than or equal to 18 years (2). All persons responding to the BRFSS questionnaire were asked whether they had health-care coverage*, which of selected preventive health services they had received, if they had a usual place of medical care, and how they perceived their health status. This analysis specifically examined preventive health services targeted by the national health objectives for the year 2000 (i.e., cholesterol screening, breast and 7cervical cancer screening, and colorectal cancer screening) (3). The use of these services, the perception of health status, and absence of a usual place of medical care were compared between persons who were insured and uninsured by calculating crude prevalence ratios and adjusted odds ratios (i.e., adjusted for age, race, education level, employment status, and income level). For this analysis, sample estimates were statistically weighted to reflect the noninstitutionalized civilian population in each state, and standard errors were calculated using SESUDAAN. Health Insurance Coverage for Persons Aged 18-64 Years Of the 102,263 persons who participated in the 1993 BRFSS, 81,794 persons aged 18-64 years responded to the question about health-care coverage. Of these respondents, 16% reported they were uninsured at the time of interview (Table 1). The percentages of persons who reported being uninsured ranged from 7% in Hawaii to 26% in Louisiana (Table 1). The prevalence of being uninsured was higher among persons in states in the West (20%; 95% confidence interval [CI]=19%-21%) and South (19%; 95% CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%; 95% CI=11%-13%).** The prevalence of being uninsured was highest among men (18%), persons aged 18-24 years (27%), those with less than a high school education (35%), those with an annual household income less than $10,000 (39%), blacks (21%), Hispanics (34%), and persons who were unemployed (44%) (Table 2). Compared with women who were insured, women who were uninsured were twofold more likely to report having no usual place of medical care (10% versus 18%), at least 50% less likely to have had both a mammogram and a clinical breast examination during the previous 2 years (69% versus 35%), and less likely to report having had a digital rectal examination during the previous 2 years (51% versus 29%) or ever having had a proctoscopy examination (32% versus 22%) (Table 3). The prevalences of self-perceived health status were similar among women who were insured and uninsured. When compared with men who were insured, uninsured men were two times more likely to report having no usual place of medical care (18% versus 41%) and half as likely to report having had their cholesterol checked (65% versus 36%) or having had a digital rectal (51% versus 27%) or a proctoscopy examination (38% versus 20%). The prevalences of self-perceived health status were similar among men who were insured and uninsured. Minnesota-Specific Data for Persons Aged 18-64 Years The Minnesota Department of Health asked all respondents 12 supplemental questions about health insurance coverage. Among the 2494 persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their employer was their primary source of coverage for health insurance. Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% (95% CI=15%-25%) of those employed in service occupational groups were uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and 21% (95% CI=19%-23%) of insured persons reported no visits to a physician during the previous year. Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%) reported the primary reason they lacked health insurance was cost. In addition, of the 102 uninsured persons with children, 53 (53%; 95% CI=35%- 55%) reported that their children did not have health-care coverage. Reported by: N Salem, PhD, Minnesota Dept of Health. BRFSS coordinators S Jackson, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPA, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, MSW, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH, Massachusetts; H McGee, MPH, Michigan; E Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New York; G Lengerich, VMD, North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, Oregon; J Romano, MPH, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm, MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin. Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: This report documents substantial variation in the state-specific prevalences of persons who report being uninsured. In addition, persons who were uninsured were less likely to have recently received preventive health services or have a regular place of medical care. The 1993 BRFSS findings are consistent with results from previous national studies indicating that uninsured persons are less likely to receive preventive health services (4). Lack of health-care coverage also has been associated with delayed medical care and use of fewer medical services (5,6). The findings in this report indicate that uninsured persons are more likely to be younger, less educated, of races other than white, unemployed, and of low income. These persons are less likely to engage in preventive practices that can be effectively encouraged in the primary health-care setting. Because lack of insurance is associated with limited access to important preventive health-care services, improvements in health insurance coverage through health-care reform at the state level may improve access to preventive health services. The state-added questions from Minnesota are assisting in identifying uninsured groups and estimating the percentage of children who are uninsured. These findings are critical for targeting specific populations that are uninsured and developing health-care reform and managed-care strategies. The findings in this report are subject to at least three limitations. First, because the BRFSS includes only households with a telephone, these findings probably underestimate the prevalence of being uninsured among persons not residing in households with telephones (e.g., persons living below the poverty level, less educated persons, and unemployed persons). Second, nonrespondents or refusals in households with a telephone may be younger and less educated persons who are more likely to be uninsured. Third, because estimates are based on self-reported data, responses cannot be validated and are subject to recall bias. The BRFSS can be used to provide routinely available, timely, state-specific data on health insurance coverage and receipt of preventive health services that may be used to monitor the progress of health-care reform efforts in each state. This information may assist state planners in evaluating progress toward the national health objectives for the year 2000 related to chronic diseases and disabling conditions. In addition, the BRFSS enables states to add specific questions, such as those included in Minnesota, to expand health-related information for use in planning and evaluating state-based strategies for all groups. References 1. Snider S, Boyce S. Sources of health insurance and characteristics of the uninsured: analysis of the March 1993 Current Population Survey. Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI special report no. SR-20; issue brief no. 145). 2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:4-1-4-17. 3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 254). 5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance. JAMA 1988;259:2872-4. 6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325- 31. * All respondents were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?" Persons who reported having no health-care coverage at the time of the interview were considered to be uninsured. ** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. ______________________________________________________________________ | This is broadcast from the Occ-Env-Med-L Mail-list, which originates | | at Duke University Medical Center. ATSDR's support (Agency for Toxic | | Substances & Disease Registry) is provided through AOEC (Assoc'n of | | Occupational & Environmental Clinics). Intended participants are | | *clinicians* and other health professionals interested in preventive | | and medical aspects of occupational and environmental health. | ---------------------------------------------------------------------- A Fidonet-backbone echo featuring disability/medical news and information, ABLEnews is carried by more than 480 BBSs in the US, Canada, Australia, Great Britain, Greece, New Zealand, and Sweden. The echo, available from Fidonet and Planet Connect, is gated to the ADANet, FamilyNet, and World Message Exchange networks. 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