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State-Specific Prevalence Estimates of Uninsured and Underinsured Persons -- Behavioral Risk Factor Surveillance System, 1995

In the United States, cost of health-care services is a barrier to accessibility of health care, and persons often do not seek medical care because of concerns about cost, regardless of whether they have health insurance (1,2). In addition, three fourths of persons in the United States who have difficulties paying their medical bills have some type of health insurance (1). Although the affordability of health care among persons without health insurance has been described, characterization of affordability among persons who are underinsured is limited (3). To determine state-specific estimates of the prevalence of persons aged 18-64 years who are either uninsured or underinsured using an experiential definition of underinsurance, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which document variations in state-specific rates for adequate insurance coverage.

The BRFSS is a state-based, random-digit-dialed telephone survey of the U.S. noninstitutionalized population aged greater than or equal to 18 years. Data were obtained from all 50 states participating in the 1995 BRFSS. A total of 90,691 persons responded (range across states: 944-3398). Analyses were restricted to persons aged 18-64 years. Sample estimates were statistically weighted on the basis of sex, age, and race to reflect the noninstitutionalized civilian population of each state. The presence of health insurance was based on responses to the question "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?" Failure to seek medical care because of cost was based on responses to the question "Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?" Adequate insurance was defined as being insured and reporting no problems because of cost, and underinsurance was defined as being insured but failing to see a doctor because of cost. Additional state-specific analyses examined the prevalence of adequate insurance, underinsurance, and lack of insurance among persons by employment status (i.e., employed for wages, self-employed, or unemployed).

During 1995, 67.8%-87.9% of persons aged 18-64 years were adequately insured (Table_1); however, approximately one fifth were either underinsured (range: 4.3%-9.0%) or uninsured (range: 6.8%-24.6%). The prevalence of adequate coverage was highest in Hawaii (87.9%), the only state to have nearly universal health-care coverage (4). The prevalence of adequate insurance was higher in states in the northern plains and the upper Midwest and lower in states in the South, Southwest, and West (Figure_1). Underinsurance and lack of insurance were most common among the unemployed (ranges: 1.2%-21.0% and 24.0%-60.0%, respectively). Persons who were self-employed were more frequently uninsured (range: 4.7%-36.8%) than those employed for wages (range: 3.6%-21.0%) but reported similar estimates of underinsurance (range: 1.7%-11.7%). Among persons employed for wages, estimates of either underinsured or uninsured persons ranged from 7.9% (Hawaii) to 28.0% (Louisiana) Table_2.

Reported by the following BRFSS coordinators: J Cook, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; D McTague, MS, Florida; E Pledger, MPA, Georgia; J Cooper, MA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; P Arbuthnot, Mississippi; T Murayi, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; Y Gladman, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; L Redman, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. DL Warner, MPH, Epidemiology and Prevention Br, Georgia Div of Public Health. Health Care and Aging Studies Br and Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The finding in this report that 6.8%-24.6% of persons aged 18-64 years in the United States during 1995 were uninsured is consistent with previous national estimates (3,5). Previous reports have indicated a decline in the proportion of persons in the United States with health insurance, including a decline among employed persons (3,5). The BRFSS analysis also indicates that most persons who were uninsured or underinsured were employed, and approximately one fifth of employed adults were either uninsured or underinsured, possibly reflecting the inadequacy of employer-based health-care coverage (3).

The findings in this report are subject to at least two limitations. First, only residences with telephones were surveyed. Because households without telephones generally have lower incomes than those with telephones, the percentages of uninsured and underinsured persons may have been underestimated (6). Second, estimates of underinsurance were based on a relatively simple definition of underinsurance that differs from the econometric and perceptual terms used previously (7); this definition requires further evaluation to determine its accuracy.

Many studies examining trends in health-care coverage or the impact of health-care coverage on health-care status, receipt of services, or health outcomes have characterized persons as either "insured" or "uninsured." Developing a standardized working definition for monitoring underinsurance is a priority. Because the question used to define "underinsured" in the state-based BRFSS has been used frequently in national surveys, this definition enables states to compare their rates of underinsurance with national estimates and to better characterize the population segments that lack adequate health insurance.

References

  1. Blendon RJ, Donelan K, Hill CA, Carter W, Beatrice D, Altman D. Paying medical bills in the United States: why health insurance isn't enough. JAMA 1994;271:949-51.

  2. Berk ML, Schur CL, Cantor JC. Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey. Health Aff 1995;14:139-46.

  3. Monheit AC. Underinsured Americans: a review. Annu Rev Public Health 1994;15:461-85.

  4. Gilbert FI Jr, Nordyke RA. The case for restructuring health care in the United States: the Hawaii paradigm. J Med Syst 1993;17:283-8.

  5. Snider SC. Who are the medically uninsured in the United States? Stat Bull 1994;75:20-30.

  6. Thornberry OT, Massey JT. Trends in United States telephone coverage across time and subgroups. In: Groves RM, ed.: Telephone survey methodology. New York: John Wiley & Sons, 1988:25-49.

  7. Bashshur R, Smith DG, Stiles RA. Defining underinsurance: a conceptual framework for policy and empirical analysis. Med Care Rev 1993;50:199-218.


Table_1
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TABLE 1. Percentage of persons aged 18-64 years who were adequately insured,
underinsured, or uninsured, by state -- United States, Behavioral Risk Factor
Surveillance System, 1995
=========================================================================================
                      Adequately insured         Underinsured             Uninsured
                      ------------------       ----------------        ----------------
State                   %      (95% CI*)        %     (95% CI)          %     (95% CI)
---------------------------------------------------------------------------------------
Alabama                76.6    (+/-2.5%)       6.9    (+/-1.4%)        16.5   (+/-2.2%)
Alaska                 75.7    (+/-3.2%)       8.0    (+/-1.9%)        16.3   (+/-2.9%)
Arizona                76.0    (+/-2.8%)       5.5    (+/-1.4%)        18.5   (+/-2.7%)
Arkansas               73.9    (+/-2.5%)       7.5    (+/-1.4%)        18.6   (+/-2.3%)
California             70.2    (+/-2.5%)       7.2    (+/-1.4%)        22.6   (+/-2.3%)
Colorado               79.0    (+/-2.3%)       4.5    (+/-1.1%)        16.5   (+/-2.2%)
Connecticut            82.3    (+/-2.3%)       6.2    (+/-1.5%)        11.4   (+/-2.0%)
Delaware               81.0    (+/-2.2%)       5.6    (+/-1.2%)        13.4   (+/-1.9%)
Florida                72.6    (+/-2.0%)       8.2    (+/-1.2%)        19.2   (+/-1.8%)
Georgia                79.9    (+/-2.1%)       8.8    (+/-1.4%)        11.3   (+/-1.7%)
Hawaii                 87.9    (+/-1.9%)       5.3    (+/-1.4%)         6.8   (+/-1.5%)
Idaho                  74.9    (+/-1.9%)       8.1    (+/-1.2%)        17.0   (+/-1.7%)
Illinois               80.1    (+/-2.0%)       6.5    (+/-1.2%)        13.4   (+/-1.7%)
Indiana                81.4    (+/-2.0%)       6.5    (+/-1.2%)        12.1   (+/-1.6%)
Iowa                   83.9    (+/-1.5%)       4.5    (+/-0.8%)        11.6   (+/-1.4%)
Kansas                 80.4    (+/-2.1%)       6.2    (+/-1.3%)        13.4   (+/-1.9%)
Kentucky               74.0    (+/-2.3%)       9.0    (+/-1.4%)        17.0   (+/-2.0%)
Louisiana              67.8    (+/-2.8%)       7.6    (+/-1.6%)        24.6   (+/-2.6%)
Maine                  76.0    (+/-3.0%)       4.5    (+/-1.3%)        19.6   (+/-2.8%)
Maryland               84.1    (+/-1.3%)       5.2    (+/-0.7%)        10.7   (+/-1.1%)
Massachusetts          81.9    (+/-2.3%)       5.8    (+/-1.4%)        12.3   (+/-2.0%)
Michigan               83.2    (+/-1.8%)       6.8    (+/-1.2%)        10.0   (+/-1.4%)
Minnesota              84.7    (+/-1.4%)       5.8    (+/-0.9%)         9.5   (+/-1.1%)
Mississippi            74.3    (+/-2.9%)       9.0    (+/-1.7%)        16.8   (+/-2.5%)
Missouri               75.3    (+/-2.9%)       6.6    (+/-1.4%)        18.1   (+/-2.7%)
Montana                72.7    (+/-3.1%)       7.8    (+/-1.8%)        19.5   (+/-2.7%)
Nebraska               84.1    (+/-2.2%)       6.3    (+/-1.4%)         9.7   (+/-1.8%)
Nevada                 78.3    (+/-2.5%)       6.4    (+/-1.4%)        15.3   (+/-2.2%)
New Hampshire          79.5    (+/-2.8%)       6.0    (+/-1.5%)        14.5   (+/-2.5%)
New Jersey             81.3    (+/-2.9%)       8.9    (+/-2.0%)         9.9   (+/-2.3%)
New Mexico             71.3    (+/-3.2%)       7.1    (+/-1.6%)        21.7   (+/-3.0%)
New York               79.6    (+/-2.2%)       6.1    (+/-1.1%)        14.3   (+/-2.0%)
North Carolina         76.7    (+/-1.9%)       8.6    (+/-1.2%)        14.6   (+/-1.6%)
North Dakota           82.9    (+/-2.1%)       4.4    (+/-1.1%)        12.8   (+/-2.0%)
Ohio                   80.3    (+/-2.9%)       6.6    (+/-1.6%)        13.1   (+/-2.5%)
Oklahoma               76.4    (+/-2.7%)       5.6    (+/-1.4%)        18.0   (+/-2.5%)
Oregon                 76.2    (+/-2.0%)       8.1    (+/-1.2%)        15.7   (+/-1.7%)
Pennsylvania           82.5    (+/-1.9%)       6.0    (+/-1.4%)        11.5   (+/-1.5%)
Rhode Island           81.5    (+/-2.3%)       5.6    (+/-1.3%)        13.0   (+/-2.0%)
South Carolina         77.6    (+/-2.3%)       8.3    (+/-1.5%)        14.2   (+/-1.9%)
South Dakota           83.0    (+/-2.2%)       6.1    (+/-1.4%)        10.9   (+/-1.8%)
Tennessee              78.5    (+/-2.2%)       8.3    (+/-1.4%)        13.2   (+/-1.9%)
Texas                  73.2    (+/-2.8%)       6.9    (+/-1.5%)        19.9   (+/-2.5%)
Utah                   80.6    (+/-2.2%)       6.8    (+/-1.4%)        12.6   (+/-1.8%)
Vermont                78.8    (+/-2.1%)       7.3    (+/-1.4%)        13.9   (+/-1.8%)
Virginia               80.1    (+/-2.4%)       6.8    (+/-1.4%)        13.1   (+/-2.0%)
Washington             79.9    (+/-1.7%)       6.6    (+/-1.0%)        13.5   (+/-1.4%)
West Virginia          71.3    (+/-2.4%)       8.8    (+/-1.3%)        19.9   (+/-2.1%)
Wisconsin              86.4    (+/-2.1%)       4.3    (+/-1.2%)         9.3   (+/-1.8%)
Wyoming                73.7    (+/-2.2%)       7.3    (+/-1.2%)        19.0   (+/-2.0%)

Median                      79.2                    6.6                     14.0
Range                    67.8-87.9                4.3-9.0                 6.8-24.6
---------------------------------------------------------------------------------------
* Confidence interval.
=========================================================================================

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Figure_1

Figure_1
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Table_2
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TABLE 2. Percentage of persons aged 18-64 years employed for wages who were
adequately insured, underinsured, or uninsured, by state -- United States, Behavioral
Risk Factor Surveillance System, 1995
=========================================================================================
                      Adequately insured         Underinsured              Uninsured
                      ------------------       ----------------        ----------------
State                   %      (95% CI*)        %     (95% CI)          %     (95% CI)
---------------------------------------------------------------------------------------
Alabama                81.5    (+/-2.8%)       6.8    (+/-1.7%)        11.7   (+/-2.4%)
Alaska                 79.4    (+/-3.9%)       8.1    (+/-2.5%)        12.6   (+/-3.3%)
Arizona                80.1    (+/-3.4%)       5.4    (+/-2.0%)        14.5   (+/-3.1%)
Arkansas               78.5    (+/-3.0%)       7.7    (+/-1.9%)        13.7   (+/-2.5%)
California             74.7    (+/-3.0%)       6.5    (+/-1.5%)        18.8   (+/-2.8%)
Colorado               82.0    (+/-2.8%)       4.4    (+/-1.3%)        13.7   (+/-2.5%)
Connecticut            87.2    (+/-2.5%)       5.3    (+/-1.7%)         7.5   (+/-2.0%)
Delaware               83.7    (+/-2.5%)       5.3    (+/-1.5%)        10.9   (+/-2.2%)
Florida                76.2    (+/-2.6%)       7.5    (+/-1.4%)        16.3   (+/-2.3%)
Georgia                83.4    (+/-2.2%)       8.4    (+/-1.6%)         8.2   (+/-1.7%)
Hawaii                 92.1    (+/-2.0%)       4.3    (+/-1.6%)         3.5   (+/-1.3%)
Idaho                  79.1    (+/-2.4%)       7.2    (+/-1.5%)        13.6   (+/-2.0%)
Illinois               83.8    (+/-2.2%)       5.4    (+/-1.2%)        10.8   (+/-1.9%)
Indiana                85.1    (+/-2.1%)       5.8    (+/-1.3%)         9.1   (+/-1.8%)
Iowa                   86.0    (+/-1.8%)       4.4    (+/-1.0%)         9.6   (+/-1.5%)
Kansas                 82.7    (+/-2.4%)       6.1    (+/-1.5%)        11.2   (+/-2.1%)
Kentucky               81.9    (+/-2.6%)       7.5    (+/-1.7%)        10.7   (+/-2.1%)
Louisiana              72.0    (+/-3.6%)       7.1    (+/-2.0%)        21.0   (+/-3.2%)
Maine                  83.1    (+/-3.3%)       3.2    (+/-1.4%)        13.7   (+/-3.1%)
Maryland               87.1    (+/-1.4%)       5.1    (+/-0.9%)         7.8   (+/-1.2%)
Massachusett           85.0    (+/-2.6%)       4.8    (+/-1.6%)        10.3   (+/-2.2%)
Michigan               86.5    (+/-2.0%)       5.4    (+/-1.3%)         8.1   (+/-1.7%)
Minnesota              86.8    (+/-1.6%)       5.4    (+/-1.0%)         7.8   (+/-1.3%)
Mississippi            81.3    (+/-3.0%)       7.7    (+/-2.0%)        11.0   (+/-2.5%)
Missouri               77.4    (+/-3.4%)       6.4    (+/-1.8%)        16.1   (+/-3.1%)
Montana                76.9    (+/-3.9%)       7.1    (+/-2.2%)        16.0   (+/-3.5%)
Nebraska               85.8    (+/-2.6%)       5.6    (+/-1.6%)         8.7   (+/-2.1%)
Nevada                 85.0    (+/-2.6%)       6.0    (+/-1.7%)         9.0   (+/-2.1%)
New Hampshire          83.4    (+/-3.0%)       6.0    (+/-1.8%)        10.6   (+/-2.5%)
New Jersey             87.0    (+/-3.2%)       6.7    (+/-2.2%)         6.4   (+/-2.5%)
New Mexico             76.1    (+/-3.8%)       7.0    (+/-2.0%)        17.0   (+/-3.6%)
New York               85.4    (+/-2.2%)       5.5    (+/-1.4%)         9.1   (+/-1.8%)
North Carolina         80.2    (+/-2.2%)       7.7    (+/-1.4%)        12.0   (+/-1.8%)
North Dakota           85.1    (+/-2.5%)       3.5    (+/-1.2%)        11.4   (+/-2.3%)
Ohio                   81.9    (+/-3.4%)       5.8    (+/-2.0%)        12.3   (+/-3.1%)
Oklahoma               79.7    (+/-3.2%)       4.7    (+/-1.6%)        15.6   (+/-3.0%)
Oregon                 80.0    (+/-2.4%)       7.8    (+/-1.6%)        12.3   (+/-1.9%)
Pennsylvania           86.5    (+/-1.9%)       4.7    (+/-1.1%)         8.8   (+/-1.6%)
Rhode Island           84.3    (+/-2.8%)       5.9    (+/-1.7%)         9.7   (+/-2.4%)
South Carolina         80.1    (+/-2.8%)       8.5    (+/-1.8%)        11.5   (+/-2.3%)
South Dakota           84.3    (+/-2.6%)       6.1    (+/-1.6%)         9.6   (+/-2.1%)
Tennessee              83.2    (+/-2.6%)       6.4    (+/-1.6%)        10.5   (+/-2.2%)
Texas                  78.5    (+/-3.2%)       7.5    (+/-2.0%)        14.0   (+/-2.7%)
Utah                   83.4    (+/-2.5%)       6.2    (+/-1.6%)        10.4   (+/-2.1%)
Vermont                81.2    (+/-2.5%)       5.6    (+/-1.4%)        13.2   (+/-2.2%)
Virginia               81.8    (+/-2.8%)       6.6    (+/-1.7%)        11.5   (+/-2.3%)
Washington             84.4    (+/-1.9%)       5.9    (+/-1.2%)         9.7   (+/-1.6%)
West Virginia          75.2    (+/-2.9%)       8.8    (+/-1.8%)        16.1   (+/-2.5%)
Wisconsin              88.4    (+/-2.4%)       3.8    (+/-1.3%)         7.8   (+/-2.1%)
Wyoming                77.9    (+/-2.7%)       7.0    (+/-1.5%)        15.1   (+/-1.2%)

Median                     81.2                    6.1                     11.2
Range                    72.0-92.1                3.2-8.5                 3.6-21.0
---------------------------------------------------------------------------------------
* Confidence interval.
=========================================================================================

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