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A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults
- Andrew P. Wilper, MD, MPH;
- Steffie Woolhandler, MD, MPH;
- Karen E. Lasser, MD, MPH;
- Danny McCormick, MD, MPH;
- David H. Bor, MD; and
- David U. Himmelstein, MD
Abstract
Background: No recent national studies have assessed chronic illness prevalence or access to care among persons without insurance in the United States.
Objective: To compare reports of chronic conditions and access to care among U.S. adults, by self-reported insurance status.
Design: Population-based survey.
Setting: National Health and Nutritional Examination Survey (1999–2004).
Participants: 12 486 patients age 18 to 64 years.
Measurements: Estimates of national rates of cardiovascular disease, hypertension, diabetes, hypercholesterolemia, active asthma or chronic obstructive pulmonary disease, previous cancer, and measures of access to care.
Results: On the basis of National Health and Nutrition Examination Survey (1999–2004) responses, an estimated 11.4 million (95% CI, 9.8 million to 13.0 million) working-age Americans with chronic conditions were uninsured, including 16.1% (CI, 12.6% to 19.6%) of the 7.8 million with cardiovascular disease, 15.5% (CI, 13.4% to 17.6%) of the 38.2 million with hypertension, and 16.6% (CI, 13.2% to 20.0%) of the 8.5 million with diabetes. After the authors controlled for age, sex, and race or ethnicity, chronically ill patients without insurance were more likely than those with coverage to have not visited a health professional (22.6% vs. 6.2%) and to not have a standard site for care (26.1% vs. 6.2%) but more likely to identify their standard site for care as an emergency department (7.1% vs. 1.1%) (P <0.001 for all comparisons).
Limitation: The study was cross-sectional and used self-reported insurance and disease status.
Conclusion: Millions of U.S. working-age adults with chronic conditions do not have insurance and have poorer access to medical care than their insured counterparts.
Article and Author Information
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Acknowledgment: The authors thank John Z. Ayanian, MD, and Sarah Hollopeter, MD, for their comments on an earlier draft of the manuscript, and Amy Cohen, Manager of Instructional Computing, Harvard School of Public Health, for her help with statistical software.
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Grant Support: By Health Resources and Service Administration National Research Service Award 5T32 HP110011 (Dr. Wilper).
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Potential Financial Conflicts of Interest: None disclosed.
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Reproducible Research Statement: Study protocol: The NHANES methodology is available from the Centers for Disease Control and Prevention (http://www.cdc.gov/nchs/about/major/nhanes/datalink.htm.) Statistical code and data set: Available from Dr. Wilper (e-mail, awilper{at}hsph.harvard.edu).
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Requests for Single Reprints: Andrew P. Wilper, MD, Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02139; e-mail, awilper{at}hsph.harvard.edu.
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Current Author Addresses: Drs. Wilper, Woolhandler, Lasser, McCormick, Bor, and Himmelstein: Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02144.
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Author Contributions: Conception and design: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, D.U. Himmelstein.
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Analysis and interpretation of the data: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.U. Himmelstein.
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Drafting of the article: A.P. Wilper, S. Woolhandler.
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Critical revision of the article for important intellectual content: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, D.U. Himmelstein.
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Final approval of the article: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, D.U. Himmelstein.
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Statistical expertise: A.P. Wilper, S. Woolhandler, D.U. Himmelstein.
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Obtaining of funding: D.H. Bor.
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Administrative, technical, or logistic support: A.P. Wilper.
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Collection and assembly of data: A.P. Wilper.
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