Insurance Coverage and Access: Implications for Health Policy By Lu Ann Aday and Ronald Andersen Data are presented from a recent survey of the United States population
comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.
A central issue in the current debate over national health insurance (NHI) is who should be covered. One key question, the answers to which could help to inform discussions on the cost-effectiveness of various options before Congress, is who needs coverage the most. For example, what persons don't have third-party coverage? How does their access to medical care compare with that of persons who have some form of private or public insurance? To what extent are the needs of persons with various forms of coverage (or no coverage at all) being met? And how satisfied are people in these groups with their ability to gain entry to the health care system? A number of criteria may be used in assessing the effectiveness of existing programs and in projecting the need for new health policy initiatives such as NHI. These criteria indude evaluations of the accessibility, cost, and quality of existing modes of service delivery. The analyses that follow focus on various dimensions of access to medical care and on how the scores on these dimensions differ for persons with some form of private third-party coverage compared to those for people who have publidy subsidized medical assistance and to those for persons The research reported here was supported by the Robert Wood Johnson Foundation (RWJF 3163) and the National Center for Health Sernices Research, DHEW (HRA 230-7640096). The tables presented in this article served as the basis for testimony by the authors at the Region V DHEW hearings on national health insurance in Chicago, Oct. 27,1977. Address communications and requests for reprints to Lu Ann Aday, Center for Health Administration Studies, University of Chicago, 5720 S. Woodlawn, Chicago, IL 60637. Dr. Aday is senior research associate, and Dr. Andersen is professor, both in the Graduate School of Business at the University of Chicago.
0017-9124/78/04036909/$02.0O/O 0 1978 Hospital Research and Educational Trust
WINTER 1978
369
ADAY &
ANDERSEN
who have neither. The uninsured should perhaps receive the most attention in the design of new initiatives in the financing and delivery of medical care. Identifying the uninsured and evaluating the magnitude of their need for coverage-compared to the publicly and privately insured-should assist in developing priorities for the allocation of both federal and private resources to those for whom the benefits of expanded access are apt to be the greatest.
Methods The data reported here were collected by the Center for Health Administration Studies and the National Opinion Research Center at the University of Chicago. Between September 1975 and February 1976 interviews were conducted with 7,787 persons in 5,432 households representing the civilian noninstitutionalized population of the United States. In each household, information was collected on one adult and one child (if a child lived in the household), both chosen through a systematically randomized sampling procedure. There was supplementary sampling of persons experiencing episodes of illness, of nonSMSA (standard metropolitan statistical area) southern blacks, and of persons of Latino heritage living in the Southwest. All computations were based on distributions weighted to correct for the oversampling of these groups. The overall response rate for the study was 85 percent [3]. Only the population under 65 years of age was included in these analyses. Since "universal" coverage is already available to the population 65 and over through Medicare, it is the population under 65 years that is apt to benefit most from expanded federal financing programs. The insurance coverage designations used here were based on responses to a question concerning whether the person was covered by a health plan. A person was characterized as having a group policy if he or she had voluntary health insurance obtained through a place of work or some other group membership (e.g., the Grange, Farm Bureau, a medical society, group retirement plan, CHAMPUS, etc.). People who reported that they bought private insurance directly and had no group policy and no coverage through Medicaid were said to have individual coverage. (In our analysis, these people were separated from those with group coverage becuse it is more difficult for them to obtain insurance, their coverage tends to be less comprehensive, and much less of the premium dollar is returned as benefit payments. A national health insurance program would most likely benefit this group much more than it would those with group coverage.) The Medicaid category included people who reported coverage through Medicaid, public aid, or health care centers where they could get care at no cost or at reduced rates (public health dinics, etc.). The uninsured were those who reported having none of the above types of private or public financial coverage. Some of those classed as uninsured may HEALTH have been covered by categoric health care programs such as Veterans Administration programs or Workmen's Compensation, but the number of uninsured participating in such plans is small (around 12 percent) 370 and most such plans offer limited benefits.
SERVICH
Results
HEALTH INSURANCE
Type of Insurance Coverage According to the survey, the percentage of the U.S. population under 65 years of age in each insurance-coverage group was as follows in 1976:
COVERAGE
72 percent Group policy 10 percent Individual policy 7 percent Medicaid or reduced-price care 12 percent Uninsured Therefore an estimated 82 percent of people under 65 had some form of voluntary health insurance at that time. This estimate falls midway between the 1974 estimates provided by the Health Insurance Assodation of America (HIAA) [1] and the Office of Research and Statistics (ORS) in the Social Security Administration [2] of the proportion of the under-65 population having some type of hospitalization insurance, 85.2 percent and 79.9 percent, respectively. The correspondence of our figure with the HIAA and ORS data suggests that it is a reasonably valid estimate. In addition, 7 percent of the respondents reported that they had Medicaid or public aid coverage for medical expenses but no form of private third-party insurance. Twelve percent of those under 65-over 22 million persons-reported having neither private insurance nor Medicaid/public aid. Of this uninsured group, 2.3 percent said they were covered by Medicare (which is available to selected categories of sick and disabled persons under 65), 5 percent said they were covered by Workmen's Compensation, 4.7 percent said they were eligible for Veterans Administration benefits, and fewer than 1 percent said they could obtain private charity or some other form of financial assistance. Of the 22 million people with no private insurance coverage or Medicaid eligibility, 2 to 3 million had at least one of these forms of categoric coverage available to them. Socioeconomic Characteristics A detailed profile of the characteristics of these various groups can be found in ref. 3. Basically the profile conforms to that provided by other sources (e.g., ref. 4). Whereas persons with private insurance coverage tend to be older, white, middle-class suburban dwellers and Medicaid eligibles are predominately low-income, nonwhite, inner-ity AFDC children and mothers, the uninsured fall somewhere in between. They tend to be young adults living in large cities who have somewhat less than middle-class- incomes. A larger proportion, compared to the other insurance groups, are represented by Latino heritage minorities. There is a much greater probability that people who have group or individual voluntary insurance coverage are working full time in a professional or managerial capacity. A large proportion of those who purchase their own insurance are self-employed. On the other hand, WINTER the majority of Medicaid-eligible persons are unemployed; they are 1978 either laid off, permanently unable to work, or keeping house. Those who do work full time usually have jobs that are not only low-paying 371
ADAY & ANDERSEN
but also of a seasonal or temporary nature. More than half of the uninsured do work full time, about 25 percent in businesses they own themselves. The majority of the uninsured who work are employed in less-prestigious occupation categories, however, e.g., farmers, bus drivers, service workers. The uninsured then appear to be a group in between the economic statuses represented by those with private insurance coverage and those with public coverage. The uninsured have jobs that are less prestigious and that do not pay as well as the jobs of those who have private insurance, but few are poor enough to qualify for Medicaid and other reduced-price forms of care available to those classified as medically indigent [3]. Access to and need for care for the four insurance-coverage groups are shown in Tables 1-3. The figures provide some understanding of the effect that having some form of health insurance has on people's ability to use the resources of the health care system. Source of Care Having a regular source of medical care is one important indicator of potential access to the health care system. As can be seen in Table 1, the uninsured were more apt than the insured to report having no one place or provider they would go to should the need for health care arise. Over 20 percent of the people on Medicaid said that there was one place they did usually go, but that they did not see any one doctor there. For both the Medicaid and the uninsured populations, the regular source of care was more likely to be a hospital outpatient department or emergency room than was the case for privately insured individuals. When people who did not have a regular source of care were asked why they did not have one, most said it was because they were seldom sick. The uninsured in particular were apt to cite this reason. Medicaid-eligible persons were more likely to cite other reasons such as that they could not afford a private doctor or that if a medical emergency should arise they would probably go to an emergency room for treatment.
Perceived Need for Health Care and Health Services Utilization In spite of the reason cted most frequently by the uninsured for not having a regular source of medical care (i.e., no need for one), the uninsured tended to report lower perceived health levels and more disability days, on average, than privately insured individuals. The need reported by Medicaid-eligible persons was even greater than that reported by the uninsured. The percentage of each insurance-coverage group reporting their health as fair or poor was as follows: Group policy Individual policy HEALTH
SERVICES RESEARCH
372
mmf;,rn;l nr- rl.l..-e care
iVL.uA1m uJ lUUuLccuJpce Uninsured
12 percent 13 percent QA
percent &
25 percent
As shown in Table 2, however, the percentage of Medicaid enrollees who had seen a physician at least once during the year was very similar
Table 1. Source of Medical Care for Perons Under 65 Years of Age, by Type of Insurance Coverage, 1976 Total Type of insurance coverage indi- Medicaid Source of caGe vidual or reduced- isrd Gpoliup ins- [SOn at'u poiy policy price care
HEALTH
INSURANCE COVERAGE
undern6u
Regular source of care, % distribution* Particular MD/osteopath.. 80(0.8)t Regular source, no particular MD/osteopath 9(0.6) No regular source . 11(0.6) Location of regular source of care, % distribution* Private physician's office ... 92(0.6) Company or school clinic .. 1 (0.2) Other publicly supported clinic .1(02) Hospital outpatient dept or emergency room. 6(05) Reason for no regular source of care, % disributioni Seldom sick, no need ...... 42(3.0) Recently moved to area ... 17(2.2) Former physician retired, 10(1.9) died, sick, etc Usually see several
66(2.0)
78
23 (1.7)
11(1.3)
10 13
72(3.0) 1(0.4)
82(1.9) 1(0.4)
90 1
4(1.3)
4(1.0) 14(1.7)
1
43
83 (2.0)
65 (2.6)
6(1.1) 11(1.5)
22(2.2)
13 (1.8)
96(1.1)
1(0.4)
0(0.0) 3(0.8)
23(2.5)
42 (7.3) 12(4.8)
31(6.8) 7(3.7)
50(4.3)
16(2.8)
16
14(5.1)
8(3.9)
8(2.3)
9
8
9 7 (2.1) 9(1.8) 10 (4.5) 13 (4.9) physicians. Don't like phydsans 5 4(2. in general. 3(1.4) 6(3.5) 6(1.5) 18 16 (3.1) 16 (5.4) 38** (7.2) .16 (2.2) Other reasons Percent of US. population represented in this breakdown = 89; percent 0 66 years or gave no answer (NA) = 11. t Numbes in parentheses are estimited standard errors of the estimates. * Percent of US. population represented in this b kdown = 78; percent > 65 years, without a regular source of care, or NA = 22. § Respondents may have given more than one reason for not having a regular source of care; percetages reflect number of times reason was given as a proportion of number of times all reasons were reported. Percent of U.S. population reporting at least one reason = 11; percent with regular source of care, > 65 years, or NA = 89. Other reasons included: not able to afford a private physician, would go to hospital emergency room.
X
to the figure for those who had some form of private coverage, whereas the percentage of the uninsured who reported such a contact was considerably lower. The proportion hospitaized was generally higher for Medicaid enrollees than for either the privately insured or the uninsured. The uninsured tended to resemble the privately insured in terms of average physican visits overall and proportion hospitalized. The proportion of the uninsured who reported having had a preventive exam in the year, however, was somewhat lower than for either the WINTER 1978 publidy or privately insured groups. Symptoms-Response Ratio. The symptoms-response ratio is a measure that incorporates a physican norm of the number of people with a
373
ADAY &
ANDERSEN Table 2. Ui 4 of Health Sersvi by Persons Under 65 Years of Age, by Type of Insurance Coverage, 1976 I
Type of insance coverge
Utilization measure
Group policy
Total
IndiMedicaid Un ue5 vidual or reduced- mnsured ration policy price care iu
At least one phyician visit in year precedilng
interview, %*t ............. 77 (0.9)* Mean number of physician visits in year t ............. 3.7 (0.16) At least one hospitalization in year, %t§ ............... 10(0.6) At least one preventive exam in year, %*.............. 26(0.9) Saw a physician for symptoms more (+) or less (-) often than necessary (symptom-
72(2.2)
77 (2.3)
63 (2.1)
4.0 (0.40) 4. (0.58) 3.7(0.38)
75 3.8
10(1.5)
16(2.0)
9(1.2)
10
24(2.2)
24(2.4)
19(1.7)
25
-18.9 -11.6 +6.9 -7.4 ...... 46A response ratio), % ** . * Percent of U.S. population represented in this breakdown = 89; percent ;O 65 years orNA= 11. t Estimate adjusted for age, sex, and health status differences. * Numbers in parentheses are estimated standard errors of the estimates. §Percet of U.S. ulation rentd in tis bteakdown = 87; percent > 66 years, infants, or NA = 13. ** Estimate adjusted for age and sex differences.
given symptom who should see a doctor about it and the number who actually do. A positive score on the ratio indicates that people saw a physician more often than the panel of physician judges thought necessary, and a negative score indicates that they saw one less often. These ratios were calculated using data collected from a panel of practicng community physicians in 1977. (For a further discussion of the methods used, see ref. 3, appendix E.) The scores on the symptoms-response ratio for Medicaid enrollees suggest that people in this group consulted physicians about 7 percent more often for symptoms than the panel of judges thought necessary. They saw physicians more often in response to their symptoms than any other group. It should be remembered, however, that Medicaid eligibles who have visited the physidan may be more likely to report having Medicaid coverage. Further, whereas Medicaid covers office visits to physicians, many private insurance polices do not. These factors could both contribute to the high score on the symptomsresponse ratio for the Medicaid population. The uninsured, on the other hand, saw a physican about 19 percent kss than the experts would have recommended. In summary, the preceding data suggest that the uninsured were RESEARCH less apt to have one place or provider they went to when the need arose and that although they cited having no need for one as the primary 374 reason for not having such a provider, they still reported lower health
SHERAVIC
HEALTH Table 3. Dissatisfaction with Convenience and Quality of Health INSURANCE Care Services for People Under 65, by Type of Insurance COVERAGE Coverage, 1976 (ercent of U.S. population represented in these breakdowns = 86; percent ; 65 or Percentage below national average of satisfaction, by coverage groupTo* Medicid under-65 IndiUn- jPopu vidual or reduced3pGOrohu
Aspect of care
po0iC~
policy prc care insured 48 (l.0)t 47(2.7) 64(2.6) 59(2.2) 49(1.0) 48(2.7) 58 (2.7) 52 (2.2)
taion
50 50 Quality The higher the percentage, the more people there were below the national average of satisfaction, i.e., the more disatified people there were. of the estimates. t Numbers in parenthes are estimated standaier
Convenience
.......
.......
levels than, did people with private insurance coverage. Further, whereas the utilization rates of those with Medicaid or other publidy subsidized coverage equaled. or in some cases exceeded those of the privately insured, the uninsured continued to be less apt to seek preventive care and less likely to see a physician in response to disability days and symptoms of illness than were either the publidy or privately
insured. Satisfaction Measures Table 3 shows that people with private insurance coverage registered the least dissatisfaction with the convenience and quality of the care they were able to obtain and that people on Medicaid registered the greatest dissatisfaction. Although the actual access of the Medicaid group in terms of utilization rates reflects a relatively favorable status, Table 1 (p. 373) indicates that people on Medicaid were more likely to frequent hospital outpatient departments or emergency rooms, where the waits to obtain care may be quite long and the institutional resources for providing nonemergency, front-line medical care may not be the most appropriate. The uninsured were, once again, somewhere in between in terms of their evaluations of their -expeiences with the system. They were more dissatisfied than people with private coverage but not as unhappy as people who had publidy subsidized
coverage.
Discusion Medicaid has improved the access of the poor to medical care so that now their utilization rates in many cases equal or exceed those of the privately insured. Medicaid enrollees go to hospital outpatient departments or emergency rooms for their primary medical care needs WINTER more often than do people with private insurance, and they are more 1978 dissatisfied than persons with either private coverage or no insurance at all with the convenience and quality of the care they actually obtain.
375
ADAY & ANDERSEN
HEALTH SERVICES
The uninsured, however, are much more likely than those with either public or private insurance to have no regular source of medical care. Their need for care resembles that of persons currently on Medicaid much more than that of the relatively healthier, privately insured population. However, the uninsured tend to see a physician less often both for preventive and for illness-related reasons than either Medicaid enrollees or privately insured persons. One implication of these findings is that persons who are selfemployed or who work in trades or professions that do not usually provide health insurance benefits should receive considerable attention as alterative forms of national health insurance are weighed. Another implication is that some thought should be given to the places that persons to whom coverage is extende4 are likely to go for care. The poor have always been more likely to use public dinics or emergency rooms than the nonwelfare population. The extension of financial coverage to this group has apparently not resulted in their altering the places they go to seek medical care. The findings that persons covered by Medicaid tend to use public clinics and hospital emergency rooms and may even be overutilizing services now relative to their actual need-and yet are unhappier than the population as a whole with the quality and convenience of the care they obtain-suggest that financial mechnisms ight not be enough to provide care that is reasonably high in quality and accessible at an acceptable cost. These results suggest the utility of considering health maintenance organizations (HMOs) or other organizational arrangements in tandem with expanded financial coverage to produce cost-efficient and equitable access to the resources of the health care system. There are other issues, of course, that are not addressed in this paper, such as the variation in the range of services and benefits actually available to the ostensibly insured population, the proportion of family income that the insured may have to pay for medical care because of varying deductible and coinsurance provisions, or the value of direct income redistribution vs. that of third-party fiang strategies for improving access to medical services. The data presented here do, however, provide profiles of the 22 million Americans under 65 years of age who currently have no protection against the financial burdens imposed by illness and of the publicly insured, who obtain care at higher rates than in the past but who are also more dissatisfied than the majority of Americans with the quality and convenience of that care. These groups' needs represent a place to start in considering the design of a national policy to extend the "right to health care" to all Americans. Acknowledgments. We wish to thank Grace Chiu for her auistance in prepari the tables and Marguerite O'Connell, Joyce Van Grundelle, and June Smith for typing drafts of the manuscipt.
RESEARCH REFERENCES 376
376
1. Health Insurance Institute. Survey Book of Health Insurance Data 1975-76. New York: Health Insurance Institute, 1977.
2. Mueller, MS. and PA. Piro. Private health insurance in 1974: A review of coverage, enrollment and financial experience. Soc Secur Bull 39:3 Mar. 1976. 3. Aday, L.A., R. Andersen, and G.V. Fleming. A National Survey of Access to Medical Care. Unpublished manuscipt, Center for Health Administration Studies, University of Chicago, 1978. 4. National Center for Health Statistics. Advance Data: Health Insurance Coverage, 1976. Unpublished manusaipt. Washington, DC, 1978.
HEALTH INSURANCE COVERAGE
WINTER
1978
377
comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.
A central issue in the current debate over national health insurance (NHI) is who should be covered. One key question, the answers to which could help to inform discussions on the cost-effectiveness of various options before Congress, is who needs coverage the most. For example, what persons don't have third-party coverage? How does their access to medical care compare with that of persons who have some form of private or public insurance? To what extent are the needs of persons with various forms of coverage (or no coverage at all) being met? And how satisfied are people in these groups with their ability to gain entry to the health care system? A number of criteria may be used in assessing the effectiveness of existing programs and in projecting the need for new health policy initiatives such as NHI. These criteria indude evaluations of the accessibility, cost, and quality of existing modes of service delivery. The analyses that follow focus on various dimensions of access to medical care and on how the scores on these dimensions differ for persons with some form of private third-party coverage compared to those for people who have publidy subsidized medical assistance and to those for persons The research reported here was supported by the Robert Wood Johnson Foundation (RWJF 3163) and the National Center for Health Sernices Research, DHEW (HRA 230-7640096). The tables presented in this article served as the basis for testimony by the authors at the Region V DHEW hearings on national health insurance in Chicago, Oct. 27,1977. Address communications and requests for reprints to Lu Ann Aday, Center for Health Administration Studies, University of Chicago, 5720 S. Woodlawn, Chicago, IL 60637. Dr. Aday is senior research associate, and Dr. Andersen is professor, both in the Graduate School of Business at the University of Chicago.
0017-9124/78/04036909/$02.0O/O 0 1978 Hospital Research and Educational Trust
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ADAY &
ANDERSEN
who have neither. The uninsured should perhaps receive the most attention in the design of new initiatives in the financing and delivery of medical care. Identifying the uninsured and evaluating the magnitude of their need for coverage-compared to the publicly and privately insured-should assist in developing priorities for the allocation of both federal and private resources to those for whom the benefits of expanded access are apt to be the greatest.
Methods The data reported here were collected by the Center for Health Administration Studies and the National Opinion Research Center at the University of Chicago. Between September 1975 and February 1976 interviews were conducted with 7,787 persons in 5,432 households representing the civilian noninstitutionalized population of the United States. In each household, information was collected on one adult and one child (if a child lived in the household), both chosen through a systematically randomized sampling procedure. There was supplementary sampling of persons experiencing episodes of illness, of nonSMSA (standard metropolitan statistical area) southern blacks, and of persons of Latino heritage living in the Southwest. All computations were based on distributions weighted to correct for the oversampling of these groups. The overall response rate for the study was 85 percent [3]. Only the population under 65 years of age was included in these analyses. Since "universal" coverage is already available to the population 65 and over through Medicare, it is the population under 65 years that is apt to benefit most from expanded federal financing programs. The insurance coverage designations used here were based on responses to a question concerning whether the person was covered by a health plan. A person was characterized as having a group policy if he or she had voluntary health insurance obtained through a place of work or some other group membership (e.g., the Grange, Farm Bureau, a medical society, group retirement plan, CHAMPUS, etc.). People who reported that they bought private insurance directly and had no group policy and no coverage through Medicaid were said to have individual coverage. (In our analysis, these people were separated from those with group coverage becuse it is more difficult for them to obtain insurance, their coverage tends to be less comprehensive, and much less of the premium dollar is returned as benefit payments. A national health insurance program would most likely benefit this group much more than it would those with group coverage.) The Medicaid category included people who reported coverage through Medicaid, public aid, or health care centers where they could get care at no cost or at reduced rates (public health dinics, etc.). The uninsured were those who reported having none of the above types of private or public financial coverage. Some of those classed as uninsured may HEALTH have been covered by categoric health care programs such as Veterans Administration programs or Workmen's Compensation, but the number of uninsured participating in such plans is small (around 12 percent) 370 and most such plans offer limited benefits.
SERVICH
Results
HEALTH INSURANCE
Type of Insurance Coverage According to the survey, the percentage of the U.S. population under 65 years of age in each insurance-coverage group was as follows in 1976:
COVERAGE
72 percent Group policy 10 percent Individual policy 7 percent Medicaid or reduced-price care 12 percent Uninsured Therefore an estimated 82 percent of people under 65 had some form of voluntary health insurance at that time. This estimate falls midway between the 1974 estimates provided by the Health Insurance Assodation of America (HIAA) [1] and the Office of Research and Statistics (ORS) in the Social Security Administration [2] of the proportion of the under-65 population having some type of hospitalization insurance, 85.2 percent and 79.9 percent, respectively. The correspondence of our figure with the HIAA and ORS data suggests that it is a reasonably valid estimate. In addition, 7 percent of the respondents reported that they had Medicaid or public aid coverage for medical expenses but no form of private third-party insurance. Twelve percent of those under 65-over 22 million persons-reported having neither private insurance nor Medicaid/public aid. Of this uninsured group, 2.3 percent said they were covered by Medicare (which is available to selected categories of sick and disabled persons under 65), 5 percent said they were covered by Workmen's Compensation, 4.7 percent said they were eligible for Veterans Administration benefits, and fewer than 1 percent said they could obtain private charity or some other form of financial assistance. Of the 22 million people with no private insurance coverage or Medicaid eligibility, 2 to 3 million had at least one of these forms of categoric coverage available to them. Socioeconomic Characteristics A detailed profile of the characteristics of these various groups can be found in ref. 3. Basically the profile conforms to that provided by other sources (e.g., ref. 4). Whereas persons with private insurance coverage tend to be older, white, middle-class suburban dwellers and Medicaid eligibles are predominately low-income, nonwhite, inner-ity AFDC children and mothers, the uninsured fall somewhere in between. They tend to be young adults living in large cities who have somewhat less than middle-class- incomes. A larger proportion, compared to the other insurance groups, are represented by Latino heritage minorities. There is a much greater probability that people who have group or individual voluntary insurance coverage are working full time in a professional or managerial capacity. A large proportion of those who purchase their own insurance are self-employed. On the other hand, WINTER the majority of Medicaid-eligible persons are unemployed; they are 1978 either laid off, permanently unable to work, or keeping house. Those who do work full time usually have jobs that are not only low-paying 371
ADAY & ANDERSEN
but also of a seasonal or temporary nature. More than half of the uninsured do work full time, about 25 percent in businesses they own themselves. The majority of the uninsured who work are employed in less-prestigious occupation categories, however, e.g., farmers, bus drivers, service workers. The uninsured then appear to be a group in between the economic statuses represented by those with private insurance coverage and those with public coverage. The uninsured have jobs that are less prestigious and that do not pay as well as the jobs of those who have private insurance, but few are poor enough to qualify for Medicaid and other reduced-price forms of care available to those classified as medically indigent [3]. Access to and need for care for the four insurance-coverage groups are shown in Tables 1-3. The figures provide some understanding of the effect that having some form of health insurance has on people's ability to use the resources of the health care system. Source of Care Having a regular source of medical care is one important indicator of potential access to the health care system. As can be seen in Table 1, the uninsured were more apt than the insured to report having no one place or provider they would go to should the need for health care arise. Over 20 percent of the people on Medicaid said that there was one place they did usually go, but that they did not see any one doctor there. For both the Medicaid and the uninsured populations, the regular source of care was more likely to be a hospital outpatient department or emergency room than was the case for privately insured individuals. When people who did not have a regular source of care were asked why they did not have one, most said it was because they were seldom sick. The uninsured in particular were apt to cite this reason. Medicaid-eligible persons were more likely to cite other reasons such as that they could not afford a private doctor or that if a medical emergency should arise they would probably go to an emergency room for treatment.
Perceived Need for Health Care and Health Services Utilization In spite of the reason cted most frequently by the uninsured for not having a regular source of medical care (i.e., no need for one), the uninsured tended to report lower perceived health levels and more disability days, on average, than privately insured individuals. The need reported by Medicaid-eligible persons was even greater than that reported by the uninsured. The percentage of each insurance-coverage group reporting their health as fair or poor was as follows: Group policy Individual policy HEALTH
SERVICES RESEARCH
372
mmf;,rn;l nr- rl.l..-e care
iVL.uA1m uJ lUUuLccuJpce Uninsured
12 percent 13 percent QA
percent &
25 percent
As shown in Table 2, however, the percentage of Medicaid enrollees who had seen a physician at least once during the year was very similar
Table 1. Source of Medical Care for Perons Under 65 Years of Age, by Type of Insurance Coverage, 1976 Total Type of insurance coverage indi- Medicaid Source of caGe vidual or reduced- isrd Gpoliup ins- [SOn at'u poiy policy price care
HEALTH
INSURANCE COVERAGE
undern6u
Regular source of care, % distribution* Particular MD/osteopath.. 80(0.8)t Regular source, no particular MD/osteopath 9(0.6) No regular source . 11(0.6) Location of regular source of care, % distribution* Private physician's office ... 92(0.6) Company or school clinic .. 1 (0.2) Other publicly supported clinic .1(02) Hospital outpatient dept or emergency room. 6(05) Reason for no regular source of care, % disributioni Seldom sick, no need ...... 42(3.0) Recently moved to area ... 17(2.2) Former physician retired, 10(1.9) died, sick, etc Usually see several
66(2.0)
78
23 (1.7)
11(1.3)
10 13
72(3.0) 1(0.4)
82(1.9) 1(0.4)
90 1
4(1.3)
4(1.0) 14(1.7)
1
43
83 (2.0)
65 (2.6)
6(1.1) 11(1.5)
22(2.2)
13 (1.8)
96(1.1)
1(0.4)
0(0.0) 3(0.8)
23(2.5)
42 (7.3) 12(4.8)
31(6.8) 7(3.7)
50(4.3)
16(2.8)
16
14(5.1)
8(3.9)
8(2.3)
9
8
9 7 (2.1) 9(1.8) 10 (4.5) 13 (4.9) physicians. Don't like phydsans 5 4(2. in general. 3(1.4) 6(3.5) 6(1.5) 18 16 (3.1) 16 (5.4) 38** (7.2) .16 (2.2) Other reasons Percent of US. population represented in this breakdown = 89; percent 0 66 years or gave no answer (NA) = 11. t Numbes in parentheses are estimited standard errors of the estimates. * Percent of US. population represented in this b kdown = 78; percent > 65 years, without a regular source of care, or NA = 22. § Respondents may have given more than one reason for not having a regular source of care; percetages reflect number of times reason was given as a proportion of number of times all reasons were reported. Percent of U.S. population reporting at least one reason = 11; percent with regular source of care, > 65 years, or NA = 89. Other reasons included: not able to afford a private physician, would go to hospital emergency room.
X
to the figure for those who had some form of private coverage, whereas the percentage of the uninsured who reported such a contact was considerably lower. The proportion hospitaized was generally higher for Medicaid enrollees than for either the privately insured or the uninsured. The uninsured tended to resemble the privately insured in terms of average physican visits overall and proportion hospitalized. The proportion of the uninsured who reported having had a preventive exam in the year, however, was somewhat lower than for either the WINTER 1978 publidy or privately insured groups. Symptoms-Response Ratio. The symptoms-response ratio is a measure that incorporates a physican norm of the number of people with a
373
ADAY &
ANDERSEN Table 2. Ui 4 of Health Sersvi by Persons Under 65 Years of Age, by Type of Insurance Coverage, 1976 I
Type of insance coverge
Utilization measure
Group policy
Total
IndiMedicaid Un ue5 vidual or reduced- mnsured ration policy price care iu
At least one phyician visit in year precedilng
interview, %*t ............. 77 (0.9)* Mean number of physician visits in year t ............. 3.7 (0.16) At least one hospitalization in year, %t§ ............... 10(0.6) At least one preventive exam in year, %*.............. 26(0.9) Saw a physician for symptoms more (+) or less (-) often than necessary (symptom-
72(2.2)
77 (2.3)
63 (2.1)
4.0 (0.40) 4. (0.58) 3.7(0.38)
75 3.8
10(1.5)
16(2.0)
9(1.2)
10
24(2.2)
24(2.4)
19(1.7)
25
-18.9 -11.6 +6.9 -7.4 ...... 46A response ratio), % ** . * Percent of U.S. population represented in this breakdown = 89; percent ;O 65 years orNA= 11. t Estimate adjusted for age, sex, and health status differences. * Numbers in parentheses are estimated standard errors of the estimates. §Percet of U.S. ulation rentd in tis bteakdown = 87; percent > 66 years, infants, or NA = 13. ** Estimate adjusted for age and sex differences.
given symptom who should see a doctor about it and the number who actually do. A positive score on the ratio indicates that people saw a physician more often than the panel of physician judges thought necessary, and a negative score indicates that they saw one less often. These ratios were calculated using data collected from a panel of practicng community physicians in 1977. (For a further discussion of the methods used, see ref. 3, appendix E.) The scores on the symptoms-response ratio for Medicaid enrollees suggest that people in this group consulted physicians about 7 percent more often for symptoms than the panel of judges thought necessary. They saw physicians more often in response to their symptoms than any other group. It should be remembered, however, that Medicaid eligibles who have visited the physidan may be more likely to report having Medicaid coverage. Further, whereas Medicaid covers office visits to physicians, many private insurance polices do not. These factors could both contribute to the high score on the symptomsresponse ratio for the Medicaid population. The uninsured, on the other hand, saw a physican about 19 percent kss than the experts would have recommended. In summary, the preceding data suggest that the uninsured were RESEARCH less apt to have one place or provider they went to when the need arose and that although they cited having no need for one as the primary 374 reason for not having such a provider, they still reported lower health
SHERAVIC
HEALTH Table 3. Dissatisfaction with Convenience and Quality of Health INSURANCE Care Services for People Under 65, by Type of Insurance COVERAGE Coverage, 1976 (ercent of U.S. population represented in these breakdowns = 86; percent ; 65 or Percentage below national average of satisfaction, by coverage groupTo* Medicid under-65 IndiUn- jPopu vidual or reduced3pGOrohu
Aspect of care
po0iC~
policy prc care insured 48 (l.0)t 47(2.7) 64(2.6) 59(2.2) 49(1.0) 48(2.7) 58 (2.7) 52 (2.2)
taion
50 50 Quality The higher the percentage, the more people there were below the national average of satisfaction, i.e., the more disatified people there were. of the estimates. t Numbers in parenthes are estimated standaier
Convenience
.......
.......
levels than, did people with private insurance coverage. Further, whereas the utilization rates of those with Medicaid or other publidy subsidized coverage equaled. or in some cases exceeded those of the privately insured, the uninsured continued to be less apt to seek preventive care and less likely to see a physician in response to disability days and symptoms of illness than were either the publidy or privately
insured. Satisfaction Measures Table 3 shows that people with private insurance coverage registered the least dissatisfaction with the convenience and quality of the care they were able to obtain and that people on Medicaid registered the greatest dissatisfaction. Although the actual access of the Medicaid group in terms of utilization rates reflects a relatively favorable status, Table 1 (p. 373) indicates that people on Medicaid were more likely to frequent hospital outpatient departments or emergency rooms, where the waits to obtain care may be quite long and the institutional resources for providing nonemergency, front-line medical care may not be the most appropriate. The uninsured were, once again, somewhere in between in terms of their evaluations of their -expeiences with the system. They were more dissatisfied than people with private coverage but not as unhappy as people who had publidy subsidized
coverage.
Discusion Medicaid has improved the access of the poor to medical care so that now their utilization rates in many cases equal or exceed those of the privately insured. Medicaid enrollees go to hospital outpatient departments or emergency rooms for their primary medical care needs WINTER more often than do people with private insurance, and they are more 1978 dissatisfied than persons with either private coverage or no insurance at all with the convenience and quality of the care they actually obtain.
375
ADAY & ANDERSEN
HEALTH SERVICES
The uninsured, however, are much more likely than those with either public or private insurance to have no regular source of medical care. Their need for care resembles that of persons currently on Medicaid much more than that of the relatively healthier, privately insured population. However, the uninsured tend to see a physician less often both for preventive and for illness-related reasons than either Medicaid enrollees or privately insured persons. One implication of these findings is that persons who are selfemployed or who work in trades or professions that do not usually provide health insurance benefits should receive considerable attention as alterative forms of national health insurance are weighed. Another implication is that some thought should be given to the places that persons to whom coverage is extende4 are likely to go for care. The poor have always been more likely to use public dinics or emergency rooms than the nonwelfare population. The extension of financial coverage to this group has apparently not resulted in their altering the places they go to seek medical care. The findings that persons covered by Medicaid tend to use public clinics and hospital emergency rooms and may even be overutilizing services now relative to their actual need-and yet are unhappier than the population as a whole with the quality and convenience of the care they obtain-suggest that financial mechnisms ight not be enough to provide care that is reasonably high in quality and accessible at an acceptable cost. These results suggest the utility of considering health maintenance organizations (HMOs) or other organizational arrangements in tandem with expanded financial coverage to produce cost-efficient and equitable access to the resources of the health care system. There are other issues, of course, that are not addressed in this paper, such as the variation in the range of services and benefits actually available to the ostensibly insured population, the proportion of family income that the insured may have to pay for medical care because of varying deductible and coinsurance provisions, or the value of direct income redistribution vs. that of third-party fiang strategies for improving access to medical services. The data presented here do, however, provide profiles of the 22 million Americans under 65 years of age who currently have no protection against the financial burdens imposed by illness and of the publicly insured, who obtain care at higher rates than in the past but who are also more dissatisfied than the majority of Americans with the quality and convenience of that care. These groups' needs represent a place to start in considering the design of a national policy to extend the "right to health care" to all Americans. Acknowledgments. We wish to thank Grace Chiu for her auistance in prepari the tables and Marguerite O'Connell, Joyce Van Grundelle, and June Smith for typing drafts of the manuscipt.
RESEARCH REFERENCES 376
376
1. Health Insurance Institute. Survey Book of Health Insurance Data 1975-76. New York: Health Insurance Institute, 1977.
2. Mueller, MS. and PA. Piro. Private health insurance in 1974: A review of coverage, enrollment and financial experience. Soc Secur Bull 39:3 Mar. 1976. 3. Aday, L.A., R. Andersen, and G.V. Fleming. A National Survey of Access to Medical Care. Unpublished manuscipt, Center for Health Administration Studies, University of Chicago, 1978. 4. National Center for Health Statistics. Advance Data: Health Insurance Coverage, 1976. Unpublished manusaipt. Washington, DC, 1978.
HEALTH INSURANCE COVERAGE
WINTER
1978
377
