The importance of insurance coverage in accessing medical services and improving health outcomes has been well documented, and over 30 million newly insured individuals could experience health improvements as a result of the Patient Protection and Affordable Care Act (PPACA). Coverage enhancements, a renewed focus on prevention, as well as incentives for safety, quality and care coordination may also create positive health effects. The ability of the health care system to effectively serve a vastly expanded insured population remains in question, however, and will be critical to the success of the reforms in improving health for individuals and families.
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A variety of components of the Patient Protection and Affordable Care Act (PPACA) have the potential not only to increase coverage and control costs but also to ultimately improve health outcomes for millions of Americans. The primary mechanism by which the reforms will improve health will be through the expansion of affordable coverage. According to the Congressional Budget Office, the reforms in the health care bill are expected to extend coverage to over 30 million individuals who would otherwise be uninsured by 2019. Such individuals are likely to experience the bulk of health improvements resulting from reform. Additional health benefits may occur, however, through improvements to existing coverage, a renewed focus on prevention and wellness, and payment reforms designed to reward quality and safety.
Health Improvements through Coverage Expansions
The mechanism through which coverage expansion is expected to improve health is by increasing access to effective medical services. Preventive services can help to avoid illness and encourage early diagnosis of many problems. Access to timely and effective treatment in the event of acute or chronic illness can further reduce morbidity and mortality. While more care does not always produce better outcomes, affordable access to medical services can improve health, and insurance is a critical component in obtaining such access to preventive care and effective treatments.
Substantial evidence exists that insurance improves both access to care and outcomes for children. Children without insurance coverage are less likely to have a usual source of medical care and more likely to report unmet medical needs. The situation is particularly dire for children with special health care needs, among whom the uninsured are six to eight times more likely to have an unmet medical need than their insured counterparts. Insured children also obtain more preventive care than uninsured children, including doctor and dentist visits, and experience a significant reduction in unmet needs for prescription drugs. Children with health insurance receive more timely diagnosis of diabetes and have fewer serious diabetes complications. Insured children also have lower rates of preventable hospitalizations. Studies show that a 10 percent increase in coverage under Medicaid reduces the rate of preventable admissions by 3 percent and that enrolling in the Children’s Health Insurance Program (CHIP) leads to an 8 percentage point reduction in asthma hospitalizations. Coverage increases resulting from the new health reform laws therefore have a strong likelihood of improving the health of newly insured children, particularly those with chronic conditions and special needs.
Insurance coverage has also been found to improve access to important medical services for adults. For example, gaining Medicare coverage at age 65 has a significant effect on preventive care utilization. Those groups most likely to be uninsured prior to age 65 exhibit increases of 5 to 10 percentage points in rates of flu vaccines, cholesterol testing, mammography and diagnosed hypertension. Moreover, gaining Medicare coverage plays a very significant role in improving general health status, reducing mortality, and narrowing the health disparities that exist between high- and low-income or white and non-white adults. Individuals who gain Medicare after being uninsured show larger improvements on a summary measure of physical and mental health than those individuals who were consistently insured prior to age 65. This result is particularly pronounced for individuals with cardiovascular (CV) disease. After age 70, the health disparity between previously insured and uninsured adults with CV disease dropped by 50 percent.
Improvements in access to care and health outcomes are not limited to those gaining Medicare coverage. Non-elderly uninsured individuals are less likely to see a clinician following an unintentional injury or a new chronic condition. Those who do visit a provider are less likely to obtain recommended follow-up care, and those with an injury are less likely to fully recover before stopping treatment. A wide variety of additional evidence exists to support the more general observations that the uninsured receive less preventive care, are often diagnosed later and receive more limited treatment than insured individuals.
Ultimately, insurance affects not only access to care, use of services and a variety of general health measures, but also the probability of death from various causes. Uninsured cancer patients are more likely to be diagnosed at later stages for those cancers with viable preventive measures and, controlling for stage of diagnosis, have higher mortality rates. Acutely ill patients exhibit an abrupt drop in mortality at age 65, which implies that Medicare reduces mortality for a set of specific conditions by 20 percent. Further evidence also indicates that uninsured adults who are in serious car accidents receive 20 percent less care and have higher mortality rates than their insured counterparts. Uninsured individuals with a broader range of unintentional injuries also have fewer outpatient and office-based visits, use fewer prescription drugs, and report worse outcomes than those with insurance. In an extensive review of the literature on the consequences of uninsurance, Hadley finds estimates of the effect of gaining insurance coverage on mortality rates that range from reductions of 4 to 25 percent depending on the time period, study population and other analysis details. More recent estimates by McWilliams and colleagues, as well as by Baker and colleagues, suggest that mortality risk for near-elderly uninsured adults is 35 to 43 percent greater than for the insured.
All of the above evidence, taken together, indicates the importance of insurance in accessing necessary medical services and ultimately improving health outcomes. Thus, the coverage expansions associated with the upcoming health reforms are likely to reap significant health benefits for the newly insured population.
(End of excerpt. The full brief is available in PDF format.)