Ongoing Coverage for Ongoing Care: Access, Utilization, and Out-of-Pocket Spending Among Uninsured Working-Aged Adults with Chronic Health Care Needs

摘要

Objectives. We sought to determine how part-year and full-year gaps in health insurance coverage affected working-aged persons with chronic health care needs. Methods. We conducted multivariate analyses of the 2002–2004 Medical Expenditure Panel Survey to compare access, utilization, and out-of-pocket spending burden among key groups of persons with chronic conditions and disabilities. The results are generalizable to the US community-dwelling population aged 18 to 64 years. Results. Among 92 million adults with chronic conditions, 21% experienced at least 1 month uninsured during the average year (2002–2004). Among the 25 million persons reporting both chronic conditions and disabilities, 23% were uninsured during the average year. These gaps in coverage were associated with significantly higher levels of access problems, lower rates of ambulatory visits and prescription drug use, and higher levels of out-of-pocket spending. Conclusions. Implementation of health care reform must focus not only on the prevention of chronic conditions and the expansion of insurance coverage but also on the long-term stability of the coverage to be offered. Approximately 46 million Americans were uninsured in 2006–2007. 1 However, measures such as this one are based upon the number of individuals without coverage on a particular day; consequently, these measures record a person as insured even if that individual may have experienced a period without coverage directly preceding or following the day of measurement. The result is an undercount of persons experiencing brief spells uninsured. 2 Individuals frequently move into and out of coverage over time, 3 , 4 and persons with chronic conditions and disabilities may be particularly sensitive to the effects of even these brief periods without insurance. A number of factors have caused persons with ongoing health care needs to have difficulty obtaining and maintaining stable coverage, such as taking a job without health benefits, job loss or transition, divorce, means testing, disability determination, or waiting periods for public coverage. 5 – 8 A growing body of research documents how being uninsured can affect persons with chronic conditions, 9 – 13 and other studies have separately examined the experiences that people with disabilities have when uninsured. 7 , 8 , 14 – 16 However, these are not mutually exclusive populations, and the extent and effects of insurance coverage gaps in these groups are not well differentiated in the available literature. Existing research cautions us that insurance coverage is a dynamic process, 2 – 4 but most current studies of these groups employ point-in-time estimates of insurance coverage or limit the analysis to the long-term uninsured, potentially underestimating the extent of coverage interruptions. Furthermore, these are population groups with much to gain (or lose) as health care reform is implemented in the years to come. Unlike individuals who require simple routine care and screenings, adults with chronic health care needs have conditions that persist over time, sometimes necessitating the continuing use of a range of costly health care services. 17 In addition, persons with chronic conditions frequently have multiple long-term conditions 18 and may also develop additional acute conditions over time. 19 Although this accumulation of medical conditions is well documented in elderly populations, 20 roughly half of the working-aged population also has at least 1 chronic condition. 21 About a quarter of these persons will also report some degree of disability that may affect work and other types of community participation, as well as such fundamental activities as independently dressing, bathing, or preparing a meal. 18 , 22 Regardless of whether an individual has a single chronic condition or several, or whether that individual has a disability or not, the effort required to manage ongoing health care needs over time can be substantial, particularly in a system as specialized as ours. 23 , 24 Studies of persons with chronic conditions 18 , 19 , 21 and disabilities 7 , 25 , 26 document high utilization rates of many types of care in numerous different settings. Hence, the primary concerns for many persons with chronic conditions and disabilities include how to arrange, coordinate, and pay for care from multiple providers at the same time. 18 Indeed, even among the fully insured, out-of-pocket spending rises in a linear fashion with the number of chronic conditions reported. 27 In light of these concerns, we investigated the extent of insurance coverage gaps among working-aged adults with chronic conditions and disabilities. Although these populations have historically been studied separately, we used a combined approach bec