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Self-Assessed Health Status and Selected Behavioral Risk Factors Among Persons With and Without Health-Care Coverage -- United States, 1994-1995

Persons without health-care coverage are more likely to have poor health and be at greater risk for chronic disease outcomes than persons who have health-care coverage (1). In the United States, the number of persons and the proportion of the population without health-care coverage has increased each year since 1987 (2). State-specific surveillance of health-care coverage can be used to identify subgroups of the population who lack such coverage and may be at increased risk for poor health. To determine state-specific estimates of the prevalence of self-assessed health status and risk factors for chronic disease by health-care coverage status among adults aged 18-64 years, CDC analyzed data from the 1994 and 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis and indicates that adults without health-care coverage were more likely than those with health-care coverage to have poor health status, to be current smokers, and to be less physically active.

BRFSS is a state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged greater than or equal to 18 years. The 1995 BRFSS was conducted in the 50 states and the District of Columbia and was used to determine self-reported health-care coverage status and the selected risk factors of cigarette smoking, physical inactivity, and self-assessed health status among adults aged 18-64 years. To assess health-care coverage status, respondents were asked "Do you have any kind of health-care coverage, including health insurance, prepaid plans such as HMOs, or governmental plans such as Medicare?" Smoking was assessed by asking "Have you smoked at least 100 cigarettes in your entire life?" and "Do you smoke cigarettes now?" Current smokers were persons who reported having smoked greater than or equal to 100 cigarettes during their lifetimes and who smoke now. Physical inactivity was assessed by asking the respondent "During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?" Persons were considered inactive during their leisure time if they answered no to this question. For the purpose of this report, the estimates for health status reflect the proportion of persons indicating either fair or poor health status. Data from the 50 states were weighted to represent state populations and used to produce point estimates; 95% confidence intervals were calculated using SUDAAN.

During 1995, the prevalence of health-care coverage varied among states and ranged from 76.9% (Louisiana) to 93.3% (Hawaii) (median: 87.0%). The median prevalence of fair-to-poor self-assessed health status was 9.0% among persons with health-care coverage and 13.8% among those without coverage; state-specific prevalences among those with coverage ranged from 5.3% (Nebraska) to 17.3% (West Virginia), and among those without coverage, from 5.0% (New Jersey) to 27.9% (Kentucky) (Table_1).

The median prevalence of smoking among those with health-care coverage was 22.8%, compared with 39.3% among those without coverage (Table_2). The median prevalence of physical inactivity was 25.1% among those with health-care coverage, compared with 31.2% among those without coverage.

Reported by the following BRFSS coordinators: J Durham, 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; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; J Cooper, MA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; P Busick, 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; S Loyd, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, New Mexico; T Melnik, DrPH, New York; G Lengerich, VMD, 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; J Ferguson, DrPH, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; J Stones, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. Cardiovascular Health 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 findings in this report indicate that, in most states, more persons who are without health-care coverage consider themselves to be in poor or fair health than those with health-care coverage. In addition, persons without health-care coverage reported higher levels of physical inactivity and current tobacco use than did persons who have health-care coverage. Higher levels of smoking and physical inactivity are both important risk factors for many chronic disease outcomes (3).

Although the wide variation in prevalence of self-assessed health status, smoking, and physical inactivity by state may reflect, in part, differences in sociodemographic characteristics (e.g., age, race/ethnicity, income, and educational level), previous reports indicate that this variation persisted even after estimates were standardized to adjust for these differences (4). Differences in self-reported health between persons with and without coverage also may reflect factors that influence the perception of ill health (e.g., subclinical illness, lack of access to providers, and the negative effects of smoking and physical inactivity).

The findings in this report are subject to at least two limitations. First, the study excluded households without telephones; previous studies indicate substantial differences in the characteristics of persons who reside in households without a telephone compared with those who reside in households with a telephone (5). Second, these estimates were only for adults and did not include persons aged less than 18 years. To adequately assess the impact of the lack of health-care coverage, information about the health status of children and young persons also should be considered (6).

The BRFSS enables each state to document the proportion of its population without health-care coverage and the risk factor profile of this group. This information can be used to target subgroups for specific disease-prevention or health-promotion intervention efforts as well as for policy makers seeking to evaluate health-care changes at the state level. This information also can assist local and state health officials in anticipating the need for and planning of health-care and preventive-care services. The findings of this report and the results of previous studies that indicate that the number of insured in the United States increases annually and the uninsured are less likely to receive preventive-care services (7) underscore the need for state and national policies that facilitate the broadening of health-care coverage.

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. Summer L. The escalating number of uninsured in the United States. Int J Health Serv 1994;24:409-13.

  3. Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess deaths from nine chronic diseases in the United States, 1986. JAMA 1990;264:2654-9.

  4. Rowland D, Lyons B. Triple jeopardy: rural, poor, and uninsured {Review}. Health Serv Res 1989;23:975-1004.

  5. Thornberry OT, Massey JT. Trends in United States telephone coverage across time and subgroups. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nicholls WL, Waksberg J, eds. Telephone survey methodology. New York: John Wiley and Sons, 1989.

  6. Thompson RS, Taplin SH, McAfee TA, Mandelson MT, Smith AE. Primary and secondary prevention services in clinical practice: twenty years' experience in development, implementation, and evaluation. JAMA 1995;273:1130-5.

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




Table_1
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TABLE 1. Prevalence of fair-to-poor self-assessed health status among adults,
by state and health-care coverage (HCC) status -- United States, Behavioral
Risk Factor Surveillance System, 1995
==============================================================================
                          HCC                  No HCC
                  ------------------     ---------------------
State*               %      (95% CI+)       %        (95% CI)
--------------------------------------------------------------
Alabama            11.5     (+/-2.2%)     22.2      (+/-5.7%)
Alaska              6.5     (+/-1.8%)      9.7      (+/-4.4%)
Arizona            10.6     (+/-4.5%)     18.9      (+/-7.1%)
Arkansas           11.5     (+/-1.9%)     18.2      (+/-4.9%)
California         10.5     (+/-2.2%)     18.6      (+/-5.2%)
Colorado            7.8     (+/-1.5%)     13.4      (+/-5.6%)
Connecticut         6.8     (+/-1.7%)     12.5      (+/-6.3%)
Delaware           10.8     (+/-1.7%)     11.8      (+/-4.3%)
Florida             10.1    (+/-1.4%)     13.9      (+/-3.5%)
Georgia             7.6     (+/-1.5%)     16.8      (+/-5.9%)
Hawaii              9.2     (+/-1.7%)      6.8      (+/-4.8%)
Idaho               7.5     (+/-1.3%)     10.8      (+/-3.3%)
Illinois            9.6     (+/-1.5%)     18.6      (+/-5.2%)
Indiana            10.4     (+/-1.6%)     15.9      (+/-5.5%)
Iowa                7.1     (+/-1.1%)     11.0      (+/-3.8%)
Kansas              7.4     (+/-1.5%)     11.8      (+/-4.4%)
Kentucky           14.5     (+/-2.1%)     27.9      (+/-5.7%)
Louisiana          10.3     (+/-2.1%)     18.5      (+/-4.6%)
Maine               8.3     (+/-1.9%)     13.7      (+/-3.5%)
Maryland            7.4     (+/-0.9%)     13.0      (+/-3.4%)
Massachusetts       8.9     (+/-1.8%)     11.7      (+/-5.4%)
Michigan           10.5     (+/-1.5%)     13.2      (+/-4.9%)
Minnesota           6.1     (+/-0.9%)      9.0      (+/-3.3%)
Mississippi        13.9     (+/-2.4%)     25.2      (+/-6.7%)
Missouri            8.0     (+/-1.8%)     17.2      (+/-5.8%)
Montana             9.0     (+/-2.3%)     13.6      (+/-5.4%)
Nebraska            5.3     (+/-3.4%)     19.3      (+/-2.5%)
Nevada             10.3     (+/-2.1%)     19.8        (+6.7%)
New Hampshire       6.3     (+/-1.5%)     15.3      (+/-6.9%)
New Jersey          9.3     (+/-2.2%)      5.0      (+/-6.9%)
New Mexico         11.8     (+/-2.5%)     25.9      (+/-7.2%)
New York            8.5     (+/-1.4%)      7.4      (+/-3.1%)
North Carolina     13.5     (+/-1.6%)     21.2      (+/-4.9%)
North Dakota        8.7     (+/-1.8%)     13.9      (+/-5.6%)
Ohio               10.5     (+/-2.2%)     12.2      (+/-6.0%)
Oklahoma            8.1     (+/-1.8%)     18.9      (+/-6.3%)
Oregon              7.7     (+/-1.3%)     11.8      (+/-4.1%)
Pennsylvania        9.1     (+/-1.7%)     10.6      (+/-3.5%)
Rhode Island        9.2     (+/-1.7%)     17.5      (+/-6.7%)
South Carolina     10.3     (+/-1.8%)     17.2      (+/-5.2%)
South Dakota        7.7     (+/-1.7%)     13.4      (+/-5.8%)
Tennessee          13.1     (+/-1.9%)     15.1      (+/-5.6%)
Texas              11.4     (+/-2.2%)     26.0      (+/-6.4%)
Utah                7.5     (+/-1.5%)     12.6      (+/-5.0%)
Vermont             8.1     (+/-1.4%)     11.2      (+/-4.2%)
Virginia            7.7     (+/-1.7%)     17.9      (+/-5.7%)
Washington          7.5     (+/-1.1%)     12.7      (+/-3.8%)
West Virginia      17.3     (+/-2.1%)     21.7      (+/-4.8%)
Wisconsin           6.2     (+/-1.5%)      9.6      (+/-5.2%)
Wyoming             8.4     (+/-1.4%)     10.3      (+/-3.6%)

Range                   5.3-17.3               5.0-27.9
Median                    9.0                   13.8
------------------------------------------------------------------------------
* No data were available for the District of Columbia.
+ Confidence interval.
==============================================================================

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Table_2
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TABLE 2. Prevalence of cigarette smoking and physical inactivity, by state and health-care coverage (HCC) status -- United
States, Behavioral Risk Factor Surveillance System, 1994-1995
===========================================================================================================================
                                    Smoking*                                            Physical
                                                                                      inactivity+
                  -----------------------------------------------      ----------------------------------------------------
                          HCC                     No HCC                        HCC                      No HCC
                  -----------------------   ---------------------      ------------------------  --------------------------
State&               %        (95% CI@)       %        (95% CI)           %          (95% CI)       %        (95% CI)
---------------------------------------------------------------------------------------------------------------------------
Alabama             24.8      (+/-2.8%)      36.8     (+/- 6.9%)        38.5        (+/-3.3%)      56.0     (+/- 6.7%)
Alaska              23.9      (+/-3.5%)      35.5     (+/- 9.3%)        20.3        (+/-3.2%)      26.9     (+/- 8.5%)
Arizona             21.9      (+/-3.5%)      39.8     (+/- 7.9%)        20.2        (+/-3.0%)      29.4     (+/- 9.3%)
Arkansas            25.7      (+/-2.8%)      43.9     (+/- 6.7%)        30.7        (+/-3.2%)      39.0     (+/- 6.7%)
California          15.0      (+/-1.7%)      22.2     (+/- 5.4%)        18.2        (+/-1.7%)      32.9     (+/- 4.2%)
Colorado            21.5      (+/-2.4%)      35.1     (+/- 6.9%)        14.3        (+/-2.1%)      19.9     (+/- 6.0%)
Connecticut         21.2      (+/-2.5%)      35.4     (+/- 8.7%)        18.1        (+/-2.4%)      22.6     (+/- 7.2%)
Delaware            26.1      (+/-2.4%)      45.0     (+/- 7.7%)        32.0        (+/-2.8%)      42.9     (+/- 7.2%)
Florida             25.4      (+/-2.2%)      36.3     (+/- 5.0%)        25.2        (+/-2.1%)      32.6     (+/- 4.2%)
Georgia             20.8      (+/-2.1%)      32.3     (+/- 7.3%)        28.1        (+/-2.5%)      38.3     (+/- 7.0%)
Hawaii              18.8      (+/-2.4%)      30.6     (+/-11.1%)        20.3        (+/-2.4%)      22.1     (+/- 9.1%)
Idaho               18.0      (+/-1.9%)      38.7     (+/- 5.3%)        18.6        (+/-2.5%)      23.0     (+/- 5.9%)
Illinois            23.7      (+/-2.1%)      39.3     (+/- 7.0%)        30.0        (+/-2.7%)      41.6     (+/- 8.2%)
Indiana             28.2      (+/-2.3%)      49.4     (+/- 7.0%)        26.4        (+/-2.4%)      30.5     (+/- 6.3%)
Iowa                24.0      (+/-1.8%)      45.4     (+/- 6.3%)        29.9        (+/-2.4%)      36.1     (+/- 7.7%)
Kansas              22.7      (+/-2.4%)      45.9     (+/- 7.5%)        30.7        (+/-3.2%)      41.1     (+/- 9.6%)
Kentucky            27.6      (+/-2.6%)      44.2     (+/- 6.0%)        40.0        (+/-2.9%)      54.9     (+/- 5.9%)
Louisiana           24.2      (+/-2.9%)      39.7     (+/- 6.2%)        28.8        (+/-3.1%)      40.3     (+/- 6.5%)
Maine               25.9      (+/-3.3%)      40.0     (+/- 8.1%)        35.8        (+/-3.4%)      46.9     (+/- 8.8%)
Maryland            21.3      (+/-1.5%)      38.6     (+/- 5.4%)        26.8        (+/-1.8%)      32.6     (+/- 5.5%)
Massachusetts       22.0      (+/-2.6%)      38.3     (+/- 8.6%)        20.9        (+/-2.6%)      21.1     (+/- 7.2%)
Michigan            26.4      (+/-2.2%)      49.5     (+/- 7.7%)        20.8        (+/-2.1%)      23.6     (+/- 6.8%)
Minnesota           21.4      (+/-1.6%)      35.8     (+/- 6.2%)        17.8        (+/-1.5%)      28.1     (+/- 5.5%)
Mississippi         22.9      (+/-2.9%)      42.3     (+/- 8.0%)        34.2        (+/-3.3%)      44.3     (+/- 8.8%)
Missouri            24.8      (+/-2.8%)      39.7     (+/- 8.1%)        28.8        (+/-3.2%)      31.2     (+/- 7.5%)
Montana             21.0      (+/-3.0%)      32.9     (+/- 7.6%)        15.3        (+/-2.6%)      25.7     (+/- 7.3%)
Nebraska            22.1      (+/-2.4%)      53.0     (+/- 9.6%)        21.0        (+/-2.5%)      22.5     (+/- 7.3%)
Nevada              25.5      (+/-2.8%)      39.4     (+/- 7.6%)        20.1        (+/-2.5%)      21.2     (+/- 5.3%)
New Hampshire       20.0      (+/-2.6%)      40.8     (+/- 8.7%)        22.2        (+/-2.8%)      23.1     (+/- 6.8%)
New Jersey          19.6      (+/-2.9%)      39.2     (+/-12.7%)        26.3        (+/-3.1%)      33.5     (+/- 8.7%)
New Mexico          20.2      (+/-3.4%)      32.7     (+/- 7.4%)        15.9        (+/-2.8%)      24.4     (+/- 6.8%)
New York            21.9      (+/-2.3%)      38.2     (+/- 7.1%)        31.2        (+/-2.6%)      48.8     (+/- 7.5%)
North Carolina      26.6      (+/-2.1%)      41.7     (+/- 5.9%)        38.0        (+/-2.9%)      49.2     (+/- 7.0%)
North Dakota        23.3      (+/-2.6%)      41.2     (+/- 8.2%)        26.9        (+/-2.7%)      39.2     (+/- 7.5%)
Ohio                27.9      (+/-3.5%)      43.7     (+/-10.2%)        37.1        (+/-3.6%)      34.6     (+/- 9.9%)
Oklahoma            22.8      (+/-3.0%)      34.6     (+/- 7.1%)        25.1        (+/-2.9%)      32.1     (+/- 6.1%)
Oregon              22.0      (+/-2.2%)      35.7     (+/- 5.8%)        18.4        (+/-1.8%)      24.3     (+/- 4.7%)
Pennsylvania        25.4      (+/-2.3%)      43.9     (+/- 6.9%)        22.8        (+/-1.8%)      25.9     (+/- 5.9%)
Rhode Island        25.5      (+/-2.8%)      43.4     (+/- 8.4%)        25.0        (+/-1.3%)      26.8     (+/- 3.6%)
South Carolina      24.2      (+/-2.6%)      39.6     (+/- 7.1%)        28.7        (+/-2.6%)      29.5     (+/- 6.2%)
South Dakota        22.9      (+/-2.4%)      34.8     (+/- 7.9%)        26.6        (+/-2.8%)      30.4     (+/- 7.9%)
Tennessee           28.3      (+/-2.5%)      35.9     (+/- 7.4%)        36.1        (+/-2.4%)      42.9     (+/- 5.9%)
Texas               22.4      (+/-2.8%)      35.6     (+/- 6.9%)        24.1        (+/-3.1%)      37.2     (+/- 6.7%)
Utah                13.0      (+/-1.9%)      21.9     (+/- 6.6%)        17.3        (+/-2.3%)      22.2     (+/- 6.4%)
Vermont             22.3      (+/-2.3%)      43.5     (+/- 6.8%)        19.8        (+/-2.1%)      27.9     (+/- 6.0%)
Virginia            22.1      (+/-2.6%)      37.7     (+/- 7.6%)        18.7        (+/-2.5%)      27.0     (+/- 7.3%)
Washington          20.5      (+/-1.8%)      34.5     (+/- 5.5%)        17.0        (+/-1.6%)      19.9     (+/- 4.3%)
West Virginia       26.3      (+/-2.6%)      39.6     (+/- 5.6%)        40.7        (+/-2.7%)      47.5     (+/- 6.0%)
Wisconsin           23.6      (+/-2.6%)      40.3     (+/-10.5%)        22.5        (+/-2.9%)      33.4     (+/-11.3%)
Wyoming             19.4      (+/-2.1%)      39.6     (+/- 5.6%)        19.2        (+/-2.9%)      20.8     (+/- 7.5%)

Range                   13.0-28.3                21.9-53.0                   14.3-40.7                 19.9-56.0
Median                     22.8                     39.3                       25.1                       31.2
---------------------------------------------------------------------------------------------------------------------------
* Persons who reported having smoked >=100 cigarettes during their lifetimes and who smoke now.
+ During the preceding 12 months.
& No data were available for the District of Columbia.
@ Confidence interval.
===========================================================================================================================

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