Health Insurance Coverage and Receipt of Preventive Health Services -- United States, 1993

In 1992, an estimated 38.5 million U.S. residents aged less than 65 years did not have health insurance (1). Efforts by states to expand health-care coverage will require surveillance for and state-specific information about coverage for acute care and the receipt of preventive services. This report summarizes state-specific and aggregated data from the 1993 Behavioral Risk Factor Surveillance System (BRFSS) regarding the status of health insurance coverage and the receipt of preventive health services among adults aged 18-64 years. In addition, findings from the analysis of supplemental questions added to the BRFSS in Minnesota are included that address health-care utilization, source of health-care coverage, and coverage of children.

In 1993, the District of Columbia and all states except Wyoming participated in the BRFSS, a population-based, random-digit-dialed telephone survey of adults aged greater than or equal to 18 years (2). All persons responding to the BRFSS questionnaire were asked whether they had health-care coverage *, which of selected preventive health services they had received, if they had a usual place of medical care, and how they perceived their health status. This analysis specifically examined preventive health services targeted by the national health objectives for the year 2000 (i.e., cholesterol screening, breast and cervical cancer screening, and colorectal cancer screening) (3). The use of these services, the perception of health status, and absence of a usual place of medical care were compared between persons who were insured and uninsured by calculating crude prevalence ratios and adjusted odds ratios (i.e., adjusted for age, race, education level, employment status, and income level). For this analysis, sample estimates were statistically weighted to reflect the noninstitutionalized civilian population in each state, and standard errors were calculated using SESUDAAN. Health Insurance Coverage for Persons Aged 18-64 Years

Of the 102,263 persons who participated in the 1993 BRFSS, 81,794 persons aged 18-64 years responded to the question about health-care coverage. Of these respondents, 16% reported they were uninsured at the time of interview Table_1. The percentages of persons who reported being uninsured ranged from 7% in Hawaii to 26% in Louisiana Table_1. The prevalence of being uninsured was higher among persons in states in the West (20%; 95% confidence interval {CI}=19%-21%) and South (19%; 95% CI=18%-19%) than in the Northeast (14%; 95% CI=13%-15%) or Midwest (12%; 95% CI=11%-13%). **

The prevalence of being uninsured was highest among men (18%), persons aged 18-24 years (27%), those with less than a high school education (35%), those with an annual household income less than $10,000 (39%), blacks (21%), Hispanics (34%), and persons who were unemployed (44%) Table_2. Compared with women who were insured, women who were uninsured were twofold more likely to report having no usual place of medical care (10% versus 18%), at least 50% less likely to have had both a mammogram and a clinical breast examination during the previous 2 years (69% versus 35%), and less likely to report having had a digital rectal examination during the previous 2 years (51% versus 29%) or ever having had a proctoscopy examination (32% versus 22%) Table_3. The prevalences of self-perceived health status were similar among women who were insured and uninsured.

When compared with men who were insured, uninsured men were two times more likely to report having no usual place of medical care (18% versus 41%) and half as likely to report having had their cholesterol checked (65% versus 36%) or having had a digital rectal (51% versus 27%) or a proctoscopy examination (38% versus 20%). The prevalences of self-perceived health status were similar among men who were insured and uninsured. Minnesota-Specific Data for Persons Aged 18-64 Years

The Minnesota Department of Health asked all respondents 12 supplemental questions about health insurance coverage. Among the 2494 persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their employer was their primary source of coverage for health insurance. Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20% (95% CI=15%-25%) of those employed in service occupational groups were uninsured. In addition, 44% (95% CI=37%- 50%) of uninsured persons and 21% (95% CI=19%-23%) of insured persons reported no visits to a physician during the previous year.

Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%- 75%) reported the primary reason they lacked health insurance was cost. In addition, of the 102 uninsured persons with children, 53 (53%; 95% CI=35%-55%) reported that their children did not have health-care coverage. Reported by: N Salem, PhD, Minnesota Dept of Health. BRFSS coordinators S Jackson, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPA, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, MSW, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH, Massachusetts; H McGee, MPH, Michigan; E Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New York; G Lengerich, VMD, North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, Oregon; J Romano, MPH, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm, MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin. Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: This report documents substantial variation in the state-specific prevalences of persons who report being uninsured. In addition, persons who were uninsured were less likely to have recently received preventive health services or have a regular place of medical care. The 1993 BRFSS findings are consistent with results from previous national studies indicating that uninsured persons are less likely to receive preventive health services (4). Lack of health-care coverage also has been associated with delayed medical care and use of fewer medical services (5,6).

The findings in this report indicate that uninsured persons are more likely to be younger, less educated, of races other than white, unemployed, and of low income. These persons are less likely to engage in preventive practices that can be effectively encouraged in the primary health-care setting. Because lack of insurance is associated with limited access to important preventive health-care services, improvements in health insurance coverage through health-care reform at the state level may improve access to preventive health services.

The state-added questions from Minnesota are assisting in identifying uninsured groups and estimating the percentage of children who are uninsured. These findings are critical for targeting specific populations that are uninsured and developing health-care reform and managed-care strategies.

The findings in this report are subject to at least three limitations. First, because the BRFSS includes only households with a telephone, these findings probably underestimate the prevalence of being uninsured among persons not residing in households with telephones (e.g., persons living below the poverty level, less educated persons, and unemployed persons). Second, nonrespondents or refusals in households with a telephone may be younger and less educated persons who are more likely to be uninsured. Third, because estimates are based on self-reported data, responses cannot be validated and are subject to recall bias.

The BRFSS can be used to provide routinely available, timely, state-specific data on health insurance coverage and receipt of preventive health services that may be used to monitor the progress of health-care reform efforts in each state. This information may assist state planners in evaluating progress toward the national health objectives for the year 2000 related to chronic diseases and disabling conditions. In addition, the BRFSS enables states to add specific questions, such as those included in Minnesota, to expand health-related information for use in planning and evaluating state-based strategies for all groups.

References

1. Snider S, Boyce S. Sources of health insurance and characteristics of the uninsured: analysis of the March 1993 Current Population Survey. Washington, DC: Employee Benefit Research Institute, January 1994. (EBRI special report no. SR-20; issue brief no. 145).

2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:4-1-4-17.

3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1994. (Advance data no. 254).

5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance. JAMA 1988;259:2872-4.

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

* All respondents were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), 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. 

** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; and Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin.

TABLE 1. Weighted percentage of persons aged 18-64 years who were uninsured *, by
state and sex -- Behavioral Risk Factor Surveillance System, United States, + 1993
==========================================================================================================
                                   Total                        Men                   Women
                       -----------------------------     ------------------      -----------------
                       Sample
State                  size &      %      (95% CI @)      %       (95% CI)        %      (95% CI)
--------------------------------------------------------------------------------------------------
Alabama                 1694      13.1     (+/-1.7%)     12.4     (+/-2.7%)      13.7    (+/-2.3%)
Alaska                  1383      17.0     (+/-3.0%)     21.4     (+/-4.7%)      11.9    (+/-3.2%)
Arizona                 1277      19.8     (+/-3.4%)     22.4     (+/-5.6%)      17.0    (+/-3.8%)
Arkansas                1327      19.9     (+/-2.6%)     22.1     (+/-4.1%)      17.8    (+/-2.9%)
California              3071      21.3     (+/-2.0%)     24.1     (+/-3.1%)      18.4    (+/-2.3%)
Colorado                1526      18.3     (+/-2.2%)     18.3     (+/-3.3%)      18.3    (+/-3.0%)
Connecticut             1425      11.5     (+/-2.0%)     14.4     (+/-3.3%)       8.7    (+/-2.1%)
Delaware                1707      15.0     (+/-2.0%)     16.7     (+/-3.1%)      13.3    (+/-2.3%)
District of Columbia    1249      10.1     (+/-1.9%)      8.4     (+/-2.5%)      11.5    (+/-2.8%)
Florida                 2276      21.3     (+/-2.0%)     22.0     (+/-3.0%)      20.7    (+/-2.6%)
Georgia                 1815      14.9     (+/-1.9%)     14.8     (+/-2.9%)      15.0    (+/-2.5%)
Hawaii                  1830       6.9     (+/-1.4%)      8.1     (+/-2.3%)       5.7    (+/-1.6%)
Idaho                   1444      17.9     (+/-2.6%)     19.6     (+/-4.3%)      16.1    (+/-2.8%)
Illinois                1720      11.6     (+/-1.8%)     11.6     (+/-2.7%)      11.6    (+/-2.2%)
Indiana                 1633      14.1     (+/-1.9%)     14.7     (+/-3.0%)      13.5    (+/-2.5%)
Iowa                    1359      11.1     (+/-1.9%)     10.6     (11.5%)         2.4    (+/-2.7%)
Kansas                  1170      11.8     (+/-2.1%)     12.7     (+/-3.2%)      11.0    (+/-2.7%)
Kentucky                1822      19.9     (+/-2.2%)     19.5     (+/-3.1%)      20.3    (+/-2.8%)
Louisiana               1312      25.6     (+/-2.7%)     26.5     (+/-4.3%)      24.8    (+/-3.5%)
Maine                    971      15.8     (+/-2.6%)     17.6     (+/-4.1%)      14.1    (+/-3.5%)
Maryland                3560      11.7     (+/-1.3%)     12.7     (+/-2.0%)      10.8    (+/-1.6%)
Massachusetts           1282      10.1     (+/-1.9%)     11.1     (+/-2.9%)       9.1    (+/-2.4%)
Michigan                1999      11.4     (+/-1.6%)     12.6     (+/-2.5%)      10.3    (+/-2.0%)
Minnesota               2747       9.0     (+/-1.2%)     10.2     (+/-1.8%)       7.9    (+/-1.5%)
Mississippi             1268      19.4     (+/-2.6%)     18.9     (+/-3.9%)      19.9    (+/-3.3%)
Missouri                1167      14.4     (+/-2.3%)     14.4     (+/-3.4%)      14.4    (+/-2.9%)
Montana                  939      19.2     (+/-2.8%)     21.8     (+/-4.4%)      16.5    (+/-3.4%)
Nebraska                1365      11.4     (+/-1.9%)     12.0     (+/-2.9%)      10.9    (+/-2.4%)
Nevada                  1507      21.7     (+/-2.4%)     22.2     (+/-3.7%)      21.1    (+/-3.1%)
New Hampshire           1234      12.6     (+/-2.1%)     13.5     (+/-3.1%)      11.7    (+/-2.8%)
New Jersey              1227      11.5     (+/-2.1%)     13.4     (+/-3.5%)       9.6    (+/-2.4%)
New Mexico              1059      23.8     (+/-3.1%)     26.7     (+/-4.7%)      20.8    (+/-3.7%)
New York                1922      16.5     (+/-2.0%)     18.8     (+/-3.1%)      14.4    (+/-2.5%)
North Carolina          1864      14.3     (+/-1.8%)     13.4     (+/-2.6%)      15.2    (+/-2.5%)
North Dakota            1378      12.8     (+/-1.9%)     15.2     (+/-3.0%)      10.4    (+/-2.4%)
Ohio                    1065      11.7     (+/-2.3%)     13.5     (+/-3.7%)       9.9    (+/-2.7%)
Oklahoma                1148      21.8     (+/-2.7%)     22.8     (+/-4.4%)      20.8    (+/-3.5%)
Oregon                  2362      19.2     (+/-1.8%)     19.4     (+/-2.5%)      18.9    (+/-2.4%)
Pennsylvania            1868      12.6     (+/-1.8%)     13.6     (+/-2.7%)      11.8    (+/-2.4%)
Rhode Island            1438      12.0     (+/-2.1%)     15.3     (+/-3.4%)       8.7    (+/-2.4%)
South Carolina          1679      18.7     (+/-2.7%)     20.2     (+/-4.3%)      17.3    (+/-3.0%)
South Dakota            1383      12.8     (+/-2.1%)     13.6     (+/-3.1%)      11.9    (+/-2.6%)
Tennessee               2447      15.1     (+/-1.6%)     16.0     (+/-2.4%)      14.4    (+/-2.0%)
Texas                   2078      23.4     (+/-2.4%)     23.9     (+/-3.5%)      22.9    (+/-2.9%)
Utah                    1507      15.6     (+/-2.0%)     17.9     (+/-3.3%)      13.2    (+/-2.4%)
Vermont                 1550      16.4     (+/-2.2%)     18.1     (+/-3.4%)      14.7    (+/-2.7%)
Virginia                1480      13.7     (+/-2.0%)     11.8     (+/-2.8%)      15.7    (+/-2.8%)
Washington              2182      16.4     (+/-1.8%)     18.8     (+/-2.8%)      14.0    (+/-2.3%)
West Virginia           1819      19.5     (+/-2.1%)     20.3     (+/-3.3%)      18.7    (+/-2.6%)
Wisconsin               1259      12.4     (+/-2.1%)     13.3     (+/-3.2%)      11.5    (+/-2.8%)
--------------------------------------------------------------------------------------------------
* Persons who reported having no health-care coverage at the time of the interview were considered to be
  uninsured.
+ Excludes Wyoming.
& Excludes persons who said they did not know or refused to state whether they had health-care coverage.
@ Confidence interval.
==========================================================================================================

TABLE 2. Weighted percentage of persons aged 18-64 years who reported being
uninsured *, by selected sociodemographic characteristics and by sex -- Behavioral
Risk Factor Surveillance System, United States, + 1993
============================================================================================
                                         Women                             Men
                             -----------------------------     ---------------------------
                             Sample                            Sample
Characteristic                size      %       (95% CI &)      size      %      (95% CI)
------------------------------------------------------------------------------------------
Age group (yrs)
  18-24                       5,432    23.5      (+/-1.8%)      4,457    29.7    (+/-2.3%)
  25-34                      12,482    16.5      (+/-1.1%)      9,728    21.5    (+/-1.4%)
  35-44                      12,669    13.2      (+/-0.9%)     10,128    13.5    (+/-1.0%)
  45-54                       8,672    11.9      (+/-1.1%)      6,818    10.7    (+/-1.1%)
  55-64                       6,660    10.6      (+/-1.1%)      4,748     9.7    (+/-1.3%)

Education level @
  Less than high school       4,906    33.1      (+/-2.1%)      3,591     37.2   (+/-2.8%)
  High school                16,008    17.0      (+/-0.9%)     11,647     21.1   (+/-1.2%)
  Some college               13,581    12.9      (+/-0.9%)      9,757     15.7   (+/-1.2%)
  College graduate           11,378     6.8      (+/-0.8%)     10,845      7.7   (+/-0.8%)

Race/Ethnicity **
  Asian/Pacific Islander      1,189    16.6      (+/-4.1%)        974     17.2   (+/-4.1%)
  Black, non-Hispanic         4,864    20.0      (+/-1.6%)      2,869     22.7   (+/-2.1%)
  White, non-Hispanic        36,468    12.6      (+/-0.5%)     29,368     14.5   (+/-0.7%)
  Hispanic ++                 2,549    31.3      (+/-2.8%)      1,944     36.5   (+/-3.6%)

Employment status @
  Employed for wages         27,786    11.3      (+/-0.6%)     24,943     13.5   (+/-0.8%)
  Self-employed               3,114    20.1      (+/-2.1%)      4,762     26.1   (+/-1.9%)
  Unemployed                  2,524    39.4      (+/-3.1%)      1,888     49.0   (+/-3.4%)
  Other &&                   12,454    17.0      (+/-1.0%)      4,256     16.8   (+/-3.0%)

Total annual household
 income @
        <$10,000              5,456    36.8      (+/-2.1%)      2,475     43.8   (+/-3.1%)
  $10,000-19,000              8,252    29.3      (+/-1.6%)      5,483     38.2   (+/-2.2%)
  $20,000-34,999             11,835    12.4      (+/-1.0%)      9,723     16.5   (+/-1.3%)
       >=$35,000             15,775     4.2      (+/-0.6%)     15,293      6.4   (+/-0.7%)

Total                        45,915    15.2      (+/-0.5%)     35,879     17.5   (+/-0.7%)
------------------------------------------------------------------------------------------
 * Persons who reported having no health-care coverage at the time of the interview were
   considered to be uninsured.
 + Excludes Wyoming.
 & Confidence interval.
 @ Excludes unknowns.
** The number of persons in other racial groups was too small to provide reliable
   estimates.
++ Persons of Hispanic origin may be of any race.
&& Includes students, homemakers, persons unable to work, and retired persons.
============================================================================================

TABLE 3. Weighted percentage of respondents who reported fair or poor health, having no usual place of medical care, and
having obtained selected preventive health services related to year 2000 national health objectives, by sex and status of
health insurance coverage at the time of interview, -- Behavioral Risk Factor Surveillance System, United States, * 1993
==================================================================================================================================
                                                             Women                                         Men
                                         ------------------------------------------    ---------------------------------------
Characteristic                           Insured    Uninsured     OR +   (95% CI &)    Insured    Uninsured    OR    (95% CI)
------------------------------------------------------------------------------------------------------------------------------
Self-perceived fair or poor health @       9.5%       17.7%       1.1    (1.0-1.3)       8.1%       13.8%      1.2   (1.1-1.5)
Had no usual place for medical care @     10.2%       26.2%       2.6    (2.3-2.9)      18.1%       40.5%      2.4   (2.2-2.7)
Had Papanicolaou smear
  during previous 3 years @               86.9%       73.7%       0.5    (0.5-0.6)       ---         ---       ---      ---
Had cholesterol screening
  during previous 5 years @               69.3%       43.9%       0.5    (0.5-0.6)      65.0%       35.5%      0.5   (0.5-0.6)
Had both a clinical breast examination
  and a mammogram
  during previous 2 years **              69.4%       34.6%       0.3    (0.3-0.4)       ---         ---       ---      ---
Had a digital rectal examination
  during previous 2 years **              51.2%       28.8%       0.5    (0.4-0.7)      50.5%       26.7%      0.5   (0.4-0.7)
Ever had proctoscopy **                   32.0%       22.2%       0.7    (0.5-0.9)      37.9%       20.0%      0.5   (0.4-0.7)
------------------------------------------------------------------------------------------------------------------------------
 * Excludes Wyoming.
 + Odds ratio. The multivariate model is adjusted for age, race/ethnicity, education level, employment status, and income level.
 & Confidence interval.
 @ Persons aged 18-64 years.
** Persons aged 50-64 years.
==================================================================================================================================

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