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State-Specific Prevalence of Lapses in Health-Care-Insurance Coverage -- United States, 1995

Lack of health-care-insurance coverage has been associated with decreased use of preventive health services, delay in seeking medical care, and poor health status (1,2 ). In 1995, an estimated 30.5 million persons aged 18-64 years in the United States did not have health insurance (3). To determine state-specific estimates of the prevalence of persons aged 18-64 who reported either short-term (i.e., less than 12 months) or long-term (i.e., greater than or equal to 12 months) lapses in health-care coverage, CDC analyzed data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis and indicates that among adults who reported having no health insurance in 1995, most were without insurance for greater than or equal to 1 year and that long-term lapses were more prevalent among men than women.

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. Analyses were restricted to persons aged 18-64 years. Sample estimates were statistically weighted by sex, age, and race to reflect the noninstitutionalized civilian population of each state. Respondents were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, 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. Persons who were uninsured were asked "How long has it been since you had health care coverage?" Persons who reported having had coverage during the preceding year were classified as having short-term lapse, and those reporting not having had coverage for greater than or equal to 1 year were classified as having long-term lapse.

During 1995, the prevalence of persons who reported having health-care-insurance coverage ranged from 76.5% (Louisiana) to 93.3% (Hawaii) (median: 87%) (Table_1). The prevalence of reported lapses in health-care-insurance coverage of less than 1 year ranged from 1.8% (New Jersey) to 9.4% (California) (median: 4.2%); lapses of greater than or equal to 1 year ranged from 2.9% (Hawaii) to 17.1% (California) (median: 9.3%).

Among men, the percentage reporting having health-care-insurance coverage ranged from 75.5% (California) to 91.5% (Hawaii) (median: 84.7%) (Table_2). The percentage of men reporting lapses in health-care-insurance coverage of less than 1 year ranged from 2.0% (South Dakota) to 10.3% (California) (median: 4.2%), and the percentage reporting lapses of greater than or equal to 1 year ranged from 3.8% (Hawaii) to 17.1% (Texas) (median: 10.6%). Among women, the percentage reporting having health-care-insurance coverage ranged from 74.6% (Louisiana) to 95.1% (Hawaii) (median: 88%). The percentage of women reporting lapses of less than 1 year in health-care-insurance coverage ranged from 1.6% (New Jersey) to 8.5% (California) (median: 4.1%), and the percentage reporting lapses of greater than or equal to 1 year ranged from 2.0% (Wisconsin) to 17.9% (Louisiana) (median: 8.6%).

During 1995, having health-care-insurance coverage was reported more commonly by white respondents (median: 88%) than by respondents of other races/ethnicities (median: 80%), and more commonly by respondents who were employed for wages (median: 89%) than by those who were self-employed (median: 76%), homemakers (median: 82%), or unemployed (median: 61%).

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; A Onaka, PhD, 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. Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: This report documents substantial variation in the state-specific prevalence of self-reported short-term or long-term lapses in health-care-insurance coverage. State-specific variations may reflect differences in population composition (e.g., age, race/ethnicity, and sex), socioeconomic factors (e.g., per capita income, median number of years of education, and unemployment level), and other factors. Variation in health-care-insurance coverage between male and female respondents may reflect differences in coverage from public sources (e.g., Medicaid). Women are more likely than men to be covered by Medicaid through the Aid to Families with Dependent Children program because they are more likely to be caring for children (4). Race-specific differences in health-care-insurance coverage may be related to the relative income and employment status of the two groups (5). Persons employed for wages are more likely to obtain insurance through their employer, who pays all or part of the cost of coverage. In comparison, persons who are either self-employed or unemployed must pay the total cost of coverage.

BRFSS estimates can differ from those of other surveys because of differences in methodology or wording of questions. For example, BRFSS estimates of the percentage of uninsured adults aged 18-64 years were lower than those reported from the March 1996 Current Population Survey (3). Unlike the Current Population Survey, BRFSS data are based on questions about insurance status at the time of the interview, rather than during the previous calendar year. In addition, BRFSS findings may underestimate persons without health-care-insurance coverage because BRFSS excludes households without telephones; persons without a telephone are more likely to be less educated, have a lower income, or be unemployed (6).

Based on the findings of previous studies, being uninsured may be associated with declines in health status (7); in addition, compared with insured patients, those who are hospitalized while without health-care-insurance coverage may receive fewer inpatient services and may be at increased risk for dying while hospitalized (8,9). The risks associated with lack of insurance coverage may result in substantial increases in the number of persons with chronic conditions and the cost of providing care for these persons.

Although providing health-care-insurance coverage to persons with short-term lapses is important, targeting efforts toward the long-term uninsured may be more effective because of the larger number of persons in this category and because of their potentially increased health risks. The methods and findings in this report can assist state planners in evaluating the progress of efforts to improve health-care and public health and in prioritizing programs to close insurance gaps.

References

  1. Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325-31.

  2. CDC. Health insurance coverage and receipt of preventive health services -- United States, 1993. MMWR 1995;44:219-25.

  3. Bennefield RL. Health insurance coverage: 1995. Current population reports: household economic studies. Washington, DC: US Department of Commerce, Bureau of the Census, September 1996; report no. P60-195.

  4. Weissman JS, Epstein AM. Falling through the safety net: insurance status and access to health care. Baltimore: The Johns Hopkins University Press, 1994:39-41.

  5. Swartz K. The medically uninsured: special focus on workers. Washington, DC: Urban Institute Press, 1989.

  6. Bureau of the Census. Statistical brief: phoneless in America. Washington, DC: US Department of Commerce, Economics and Statistics Administration, 1994.

  7. Hahn B, Flood AB. No insurance, public insurance, and private insurance: do these options contribute to differences in general health? J Health Care Poor Underserved 1995;6:41-59.

  8. Hadley J, Steinberg EP, Feder J. Comparison of uninsured and privately insured hospital patients: conditions on admission, resource use, and outcome. JAMA 1991;265:374-9.

  9. Franks P, Clancy CM, Gold MR. Health insurance and mortality: evidence from a national cohort. JAMA 1993;270:737-41.



Table_1
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TABLE 1. Percentage of persons aged 18-64 years with reported health-care-insurance coverage, by state -- United States,
Behavioral Risk Factor Surveillance System, 1995
===========================================================================================================================
                                        Insured full                   Short-term                    Long-term
                                            year                          lapse*                       lapse+
                                    ------------------------       -----------------------     ----------------------------
State            Sample size           %           (95% CI&)         %           (95% CI)         %            (95% CI)
---------------------------------------------------------------------------------------------------------------------------
Alabama              1378            84.5          (+/-2.1%)        4.6         (+/-1.2%)        10.9         (+/-1.9%)
Alaska               1380            84.0          (+/-2.8%)        4.1         (+/-1.6%)        11.8         (+/-2.4%)
Arizona              1425            81.5          (+/-2.7%)        6.8         (+/-1.9%)        11.8         (+/-2.2%)
Arkansas             1354            82.5          (+/-2.2%)        4.8         (+/-1.3%)        12.7         (+/-1.9%)
California           3391            77.8          (+/-2.3%)        9.4         (+/-1.7%)        12.8         (+/-1.8%)
Colorado             1947            83.9          (+/-2.2%)        4.1         (+/-1.2%)        12.0         (+/-1.9%)
Connecticut          1498            89.2          (+/-1.9%)        2.5         (+/-0.9%)         8.4         (+/-1.7%)
Delaware             1674            87.2          (+/-1.9%)        3.8         (+/-1.1%)         9.0         (+/-1.6%)
Florida              2487            81.4          (+/-1.8%)        6.2         (+/-1.1%)        12.5         (+/-1.5%)
Georgia              1904            88.9          (+/-1.7%)        3.4         (+/-0.9%)         7.7         (+/-1.4%)
Hawaii               1705            93.3          (+/-1.5%)        3.9         (+/-1.2%)         2.9         (+/-0.9%)
Idaho                2160            83.6          (+/-1.7%)        5.0         (+/-1.0%)        11.3         (+/-1.4%)
Illinois             2330            86.9          (+/-1.7%)        4.5         (+/-1.1%)         8.6         (+/-1.4%)
Indiana              1880            88.0          (+/-1.6%)        4.3         (+/-1.1%)         7.7         (+/-1.3%)
Iowa                 2759            88.5          (+/-1.4%)        3.5         (+/-0.8%)         8.0         (+/-1.2%)
Kansas               1560            87.6          (+/-1.8%)        3.2         (+/-1.0%)         9.3         (+/-1.6%)
Kentucky             1749            83.8          (+/-1.9%)        3.5         (+/-0.9%)        12.7         (+/-1.8%)
Louisiana            1303            76.5          (+/-2.6%)        6.4         (+/-1.6%)        17.1         (+/-2.3%)
Maine                1008            80.4          (+/-2.8%)        7.7         (+/-2.0%)        11.8         (+/-2.3%)
Maryland             4172            89.5          (+/-1.1%)        3.8         (+/-0.7%)         6.7         (+/-0.9%)
Massachusetts        1446            87.9          (+/-2.0%)        3.3         (+/-1.2%)         8.8         (+/-1.7%)
Michigan             1995            90.2          (+/-1.4%)        3.2         (+/-0.9%)         6.6         (+/-1.2%)
Minnesota            3151            90.9          (+/-1.1%)        3.1         (+/-0.7%)         6.0         (+/-0.9%)
Mississippi          1217            83.9          (+/-2.4%)        5.1         (+/-1.5%)        11.0         (+/-2.1%)
Missouri             1244            81.9          (+/-2.7%)        4.4         (+/-1.5%)        13.7         (+/-2.3%)
Montana               939            81.0          (+/-2.7%)        3.2         (+/-1.2%)        15.8         (+/-2.6%)
Nebraska             1326            90.9          (+/-1.7%)        2.8         (+/-1.0%)         6.3         (+/-1.4%)
Nevada               1435            85.2          (+/-2.2%)        5.6         (+/-1.5%)         9.2         (+/-1.7%)
New Hampshire        1232            86.2          (+/-2.5%)        4.5         (+/-1.6%)         9.3         (+/-2.0%)
New Jersey            997            91.0          (+/-2.3%)        1.8         (+/-0.9%)         7.3         (+/-2.1%)
New Mexico           1033            79.3          (+/-3.0%)        6.1         (+/-1.6%)        14.6         (+/-2.7%)
New York             2007            86.0          (+/-2.0%)        3.9         (+/-1.0%)        10.1         (+/-1.7%)
North Carolina       2503            85.9          (+/-1.6%)        4.9         (+/-1.0%)         9.2         (+/-1.3%)
North Dakota         1359            87.7          (+/-1.9%)        2.9         (+/-0.9%)         9.4         (+/-1.7%)
Ohio                 1045            87.2          (+/-2.5%)        5.5         (+/-1.7%)         7.4         (+/-2.0%)
Oklahoma             1219            82.4          (+/-2.5%)        3.9         (+/-1.3%)        13.6         (+/-2.3%)
Oregon               2259            84.6          (+/-1.7%)        4.9         (+/-1.1%)        10.6         (+/-1.5%)
Pennsylvania         2817            88.8          (+/-1.5%)        3.9         (+/-0.9%)         7.3         (+/-1.2%)
Rhode Island         1420            87.5          (+/-2.0%)        5.2         (+/-1.4%)         7.3         (+/-1.5%)
South Carolina       1609            86.8          (+/-1.9%)        3.8         (+/-1.1%)         9.4         (+/-1.7%)
South Dakota         1355            89.7          (+/-1.8%)        2.5         (+/-0.9%)         7.8         (+/-1.5%)
Tennessee            1600            87.5          (+/-1.9%)        6.2         (+/-1.4%)         6.3         (+/-1.4%)
Texas                1400            80.8          (+/-2.5%)        4.1         (+/-1.1%)        15.1         (+/-2.4%)
Utah                 2357            87.5          (+/-1.8%)        4.9         (+/-1.1%)         7.7         (+/-1.4%)
Vermont              2001            86.3          (+/-1.8%)        3.3         (+/-0.9%)        10.5         (+/-1.6%)
Virginia             1509            87.7          (+/-1.9%)        4.6         (+/-1.2%)         7.7         (+/-1.6%)
Washington           2813            86.7          (+/-1.4%)        4.4         (+/-0.9%)         8.9         (+/-1.2%)
West Virginia        1809            80.8          (+/-2.1%)        4.6         (+/-1.1%)        14.6         (+/-1.8%)
Wisconsin            1787            91.2          (+/-1.8%)        3.4         (+/-1.3%)         5.4         (+/-1.3%)
Wyoming              1978            81.7          (+/-1.9%)        5.5         (+/-1.2%)        12.8         (+/-1.7%)

Range                                     76.5-93.3                      1.8-9.4                      2.9-17.1
Median                                       86.5                           4.2                          9.3
---------------------------------------------------------------------------------------------------------------------------
* Lacked insurance for <12 months. + Lacked insurance for>=12 months.
& Confidence interval.
===========================================================================================================================

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Table_2
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TABLE 2. Percentage of persons aged 18-64 years who reported lapses in health-care- insurance coverage, by sex and state
-- United States, Behavioral Risk Factor Surveillance System, 1995
=============================================================================================================================
                                     Short-term                                           Long-term
                                       lapse*                                               lapse+
                     ----------------------------------------------       ---------------------------------------------------
                             Men                    Women                           Men                      Women
                    --------------------------  -------------------       ------------------------    -----------------------
State                   %           (95% CI&)     %        (95% CI)         %            (95% CI)       %        (95% CI)
-----------------------------------------------------------------------------------------------------------------------------
Alabama                3.7          (+/-1.8%)    5.4      (+/-1.6%)        11.8         (+/-3.0%)     10.2      (+/-2.2%)
Alaska                 5.6          (+/-2.8%)    2.5      (+/-1.5%)        13.8         (+/-3.7%)      9.7      (+/-3.0%)
Arizona                5.8          (+/-2.7%)    7.8      (+/-2.3%)        13.1         (+/-3.6%)     10.4      (+/-2.6%)
Arkansas               4.9          (+/-1.9%)    4.8      (+/-1.5%)        11.1         (+/-2.8%)     14.3      (+/-2.7%)
California            10.3          (+/-2.8%)    8.5      (+/-1.8%)        14.2         (+/-2.5%)     11.3      (+/-2.7%)
Colorado               4.4          (+/-1.8%)    3.9      (+/-1.6%)        13.6         (+/-3.0%)     10.4      (+/-2.4%)
Connecticut            2.5          (+/-1.6%)    2.5      (+/-1.0%)        13.0         (+/-3.1%)      3.8      (+/-1.3%)
Delaware               3.5          (+/-1.7%)    4.1      (+/-1.3%)         9.5         (+/-2.6%)      8.5      (+/-2.0%)
Florida                6.2          (+/-1.7%)    6.1      (+/-1.4%)        13.2         (+/-2.4%)     11.8      (+/-1.9%)
Georgia                2.3          (+/-1.1%)    4.5      (+/-1.5%)         9.0         (+/-2.3%)      6.4      (+/-1.7%)
Hawaii                 4.7          (+/-1.9%)    3.0      (+/-1.3%)         3.8         (+/-1.5%)      2.0      (+/-1.0%)
Idaho                  3.8          (+/-1.4%)    6.3      (+/-1.5%)        11.6         (+/-2.1%)     11.1      (+/-1.8%)
Illinois               4.7          (+/-1.6%)    4.2      (+/-1.2%)         9.2         (+/-2.2%)      8.0      (+/-1.8%)
Indiana                4.2          (+/-1.6%)    4.4      (+/-1.4%)         7.6         (+/-2.0%)      7.8      (+/-1.8%)
Iowa                   3.0          (+/-1.1%)    4.0      (+/-1.1%)        10.0         (+/-1.9%)      6.0      (+/-1.3%)
Kansas                 3.7          (+/-1.6%)    2.7      (+/-1.1%)        10.4         (+/-2.5%)      8.1      (+/-2.1%)
Kentucky               3.3          (+/-1.4%)    3.6      (+/-1.2%)        12.1         (+/-2.8%)     13.3      (+/-2.3%)
Louisiana              5.2          (+/-2.2%)    7.5      (+/-2.2%)        16.3         (+/-3.6%)     17.9      (+/-2.9%)
Maine                  9.5          (+/-3.5%)    6.0      (+/-2.2%)        13.5         (+/-3.6%)     10.3      (+/-2.9%)
Maryland               3.3          (+/-1.0%)    4.2      (+/-1.0%)         8.1         (+/-1.5%)      5.4      (+/-1.0%)
Massachusetts          3.8          (+/-1.8%)    2.9      (+/-1.5%)         9.2         (+/-2.4%)      8.4      (+/-2.3%)
Michigan               3.5          (+/-1.4%)    2.9      (+/-1.1%)         7.0         (+/-1.8%)      6.1      (+/-1.6%)
Minnesota              3.0          (+/-1.0%)    3.2      (+/-0.9%)         7.3         (+/-1.5%)      4.7      (+/-1.1%)
Mississippi            5.0          (+/-2.3%)    5.2      (+/-1.9%)        12.7         (+/-3.3%)      9.5      (+/-2.6%)
Missouri               5.5          (+/-2.5%)    3.4      (+/-1.7%)        12.3         (+/-3.2%)     15.0      (+/-3.2%)
Montana                2.9          (+/-1.7%)    3.5      (+/-1.7%)        16.9         (+/-4.0%)     14.7      (+/-3.2%)
Nebraska               3.1          (+/-1.6%)    2.5      (+/-1.3%)         7.4         (+/-2.3%)      5.2      (+/-1.6%)
Nevada                 4.6          (+/-2.0%)    6.8      (+/-2.1%)         9.4         (+/-2.5%)      8.9      (+/-2.2%)
New Hampshire          5.5          (+/-2.5%)    3.5      (+/-1.7%)        10.1         (+/-3.1%)      8.5      (+/-2.6%)
New Jersey             2.1          (+/-1.5%)    1.6      (+/-1.1%)         7.2         (+/-3.6%)      7.4      (+/-2.4%)
New Mexico             5.0          (+/-2.3%)    7.1      (+/-2.4%)        16.7         (+/-4.3%)     12.5      (+/-3.2%)
New York               3.6          (+/-1.5%)    4.1      (+/-1.3%)        12.1         (+/-2.8%)      8.1      (+/-1.9%)
North Carolina         5.8          (+/-1.7%)    4.1      (+/-1.2%)         9.0         (+/-1.9%)      9.4      (+/-1.7%)
North Dakota           3.3          (+/-1.4%)    2.5      (+/-1.1%)        11.2         (+/-2.7%)      7.6      (+/-2.2%)
Ohio                   6.5          (+/-2.7%)    4.5      (+/-2.0%)         9.5         (+/-3.5%)      5.3      (+/-2.0%)
Oklahoma               4.1          (+/-2.0%)    3.7      (+/-1.8%)        14.9         (+/-3.4%)     12.4      (+/-2.9%)
Oregon                 4.2          (+/-1.4%)    5.6      (+/-1.6%)        11.6         (+/-2.2%)      9.5      (+/-1.8%)
Pennsylvania           4.1          (+/-1.4%)    3.7      (+/-1.2%)         8.6         (+/-2.0%)      6.0      (+/-1.4%)
Rhode Island           6.4          (+/-2.3%)    4.0      (+/-1.7%)         9.8         (+/-2.6%)      5.0      (+/-1.7%)
South Carolina         3.6          (+/-1.5%)    4.0      (+/-1.5%)         8.0         (+/-2.2%)     10.7      (+/-2.5%)
South Dakota           2.0          (+/-1.1%)    3.0      (+/-1.5%)         8.4         (+/-2.3%)      7.2      (+/-1.9%)
Tennessee              7.3          (+/-2.4%)    5.2      (+/-1.6%)         7.5         (+/-2.2%)      5.1      (+/-1.6%)
Texas                  3.8          (+/-1.7%)    4.5      (+/-1.5%)        17.1         (+/-3.9%)     13.1      (+/-2.6%)
Utah                   5.2          (+/-1.7%)    4.5      (+/-1.5%)         8.5         (+/-2.3%)      6.8      (+/-1.6%)
Vermont                4.2          (+/-1.5%)    2.4      (+/-1.0%)        11.8         (+/-2.4%)      9.2      (+/-2.0%)
Virginia               3.2          (+/-1.6%)    6.0      (+/-1.6%)         6.7         (+/-2.3%)      8.6      (+/-2.1%)
Washington             4.5          (+/-1.3%)    4.4      (+/-1.2%)        10.7         (+/-2.0%)      7.1      (+/-1.4%)
West Virginia          3.9          (+/-1.6%)    5.2      (+/-1.4%)        13.5         (+/-2.8%)     15.7      (+/-2.5%)
Wisconsin              4.3          (+/-2.3%)    2.5      (+/-1.2%)         5.6         (+/-2.0%)      5.2      (+/-1.7%)
Wyoming                5.3          (+/-1.6%)    5.7      (+/-1.6%)        13.4         (+/-2.5%)     12.3      (+/-2.2%)

Range               2.0-10.3                   1.6-8.5                   3.8-17.1                   2.0-17.9
Median                 4.2                       4.1                       10.6                        8.6
-----------------------------------------------------------------------------------------------------------------------------
* Lacked insurance for <12 months. + Lacked insurance for>=12 months.
& Confidence interval.
=============================================================================================================================

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