Self-Perceived Poor/Fair Health, Frequent Mental Distress, and Health Insurance Status Among Working-Aged US Adults

We examined associations of health insurance status with self-perceived poor/fair health and frequent mental distress (FMD) among working-aged US adults from 42 states and the District of Columbia using data from the 2014 Behavioral Risk Factor Surveillance System. After multiple-variable adjustment, compared with adequately insured adults, underinsured and never insured adults were 39% and 59% more likely to report poor/fair health, respectively, and 38% more likely to report FMD. Compared with working-aged adults with employer-based insurance, adults with Medicaid/Medicare or other public insurance coverage were 28% and 13% more likely to report poor/fair health, respectively, and 15% more likely to report FMD. Increasing insurance coverage and reducing cost barriers to care may improve general and mental health.

equate coverage and not being able to afford care can cause mental distress (5,6). We examined associations of health insurance coverage and type of coverage with self-perceived poor/fair health and frequent mental distress (FMD) among working-aged US adults.

Methods
The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based, landline-telephone and cellular-telephone survey of noninstitutionalized civilian US adults (7). In 2014, 42 states and the District of Columbia collected health care access data through both core and module questions, which were used for this analysis. The BRFSS protocol was approved by the Centers for Disease Control and Prevention institutional review board. The median response rate was 47.0% in 2014.
Survey participants' self-perceived health was dichotomized into poor/fair and good/very good/excellent. FMD was defined as having 14 or more days of poor mental health (including stress, depression, and problems with emotions) in the past 30 days.
The survey questions and categorization of participants' insurance status and type of insurance are described elsewhere (8). Health insurance coverage over the past 12 months was categorized as adequately insured, underinsured, and never insured. Type of coverage was categorized as employer-based, self-purchased, Medicaid or Medicare; other public or some other source, and not currently insured.
Study covariates were age, sex, race/ethnicity, education level, marital status, employment status, federal poverty level (FPL), current smoking, leisure-time physical activity, body mass index, and the number of chronic conditions/diseases including diabetes, coronary heart disease, stroke, current asthma, arthritis, cancer, chronic obstructive pulmonary disease, history of depression, kidney disease, and disability.
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Participants who responded "don't know/not sure," refused to answer, or had missing responses to any study covariates mentioned above were excluded, leaving 201,781 working-aged adults (aged 18-64 years) in the analytic sample. After further excluding participants with missing data on the 2 outcome variables, 201,423 participants remained for the analysis for self-rated poor/fair health and 199,709 participants remained for the analysis for FMD.
We estimated the weighted prevalence for self-perceived poor/fair health and FMD by health insurance coverage and type of coverage. Log-linear regression analyses were conducted to estimate adjusted prevalence ratios with 95% confidence intervals (CIs) while controlling for study covariates. SAS-callable SUDAAN (Research Triangle Institute) was used to account for the complex survey design. Significance was set at P < .05.

Results
Of 201,781 working-aged adults, the mean age was 41 years; 49.0% were women; 69.9% were non-Hispanic white; 13.5% were non-Hispanic black; and 9.8% were Hispanic. Approximately 59.9% had a degree higher than high school; 14.8% lived below the poverty level (ie, household income <100% of FPL); 20.6% were current smokers; 20.6% were physically inactive; 29.8% were obese; and 48.6% had at least 1 chronic condition or disability.
After multiple-variable adjustment for study covariates, compared with adequately insured adults, underinsured and never insured adults were 39% (P < .001) and 59% (P < .001), respectively, more likely to report poor/fair health, and 38% (P < .001 for both) more likely to report FMD (Table 2). Compared with adults with employer-based insurance, those with Medicaid/Medicare or other public coverage were more likely to report poor/fair health (28% and 13%, respectively, P < .001) and FMD (15% for both, P < .001).

Discussion
Self-assessed health status reflects concurrent decrements in health associated with physical functional status and certain chronic illnesses (1), and lower self-rated health predicts increased mortality (2,9). Poor mental health is associated with risky health behaviors and social burden (6,10). Our results from a large population survey demonstrated that self-perceived health and FMD were significantly associated with health insurance status, independent of socioeconomic status; behavioral risk factors; and multiple chronic conditions and disability. Working-aged adults who were underinsured and never insured or who had Medicaid/Medicare or other public insurance were more likely to rate their general health as poor/fair and to report FMD than their counterparts who were adequately insured or had private insurance.
Research indicates that having insurance coverage predicts better self-rated health (3,11,12) and that prevalence of FMD is significantly higher among adults with no health insurance coverage (5,6) or with financial barriers to needed medical care (5). These results are consistent with our findings that the prevalence of poor/fair health and FMD were significantly higher among underinsured and uninsured adults. Moreover, our results further demonstrated that poor/fair health and FMD were significantly higher among adults with Medicaid/Medicare or other public insurance than among those with private coverage, either employer-based or selfpurchased. Adults younger than 65 years who have Medicare or Medicaid are likely to have permanent disabilities or certain terminal diseases, or live in poverty; all of these may contribute to a higher prevalence of poor/fair health or FMD.
The strength of our study is that results are based on a large population surveillance system. BRFSS data, however, are self-reported and subject to recall bias. Also, because BRFSS excluded institutionalized adults, prevalence of poor/fair health and FMD may be underestimated. In addition, data were from 42 states and the District of Columbia, which limits generalizability of the study results to the entire US working-aged population.
Although uninsurance rates are declining in the United States (13), the trend in the rates of being underinsured or having private cov- erage are largely unknown. Continuing efforts to increase health insurance coverage and reduce cost barriers to needed medical care may help the US population achieve optimal overall health and reduce mental distress.

8.
Regidor E, Guallar-Castillón P, Gutiérrez-Fisac JL, Banegas JR, Rodríguez-Artalejo F. Socioeconomic variation in the magnitude of the association between self-rated health and mortality. Ann Epidemiol 2010;20 (5)  Abbreviations: CI, confidence interval; FMD, frequent mental distress; GED, general education diploma. a Including diabetes, coronary heart disease, stroke, current asthma, arthritis, cancer, chronic obstructive pulmonary disease, history of depression, kidney disease, and disability. Disability was defined as respondents who were limited in any way in any activities because of physical, mental, or emotional problems, or who had any health problem that required them to use special equipment (eg, cane, wheelchair, special bed, special telephone).