Higher Incomes Don't Always Bring Better Care to Uninsured

People often forego preventive tests if they must pay out-of-pocket, study finds

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By Amanda Gardner
HealthDay Reporter

TUESDAY, May 2, 2006 (HealthDay News) -- Even for relatively well-off Americans, a lack of insurance means worse care when it comes to preventive tests that can catch cancer and other diseases early, a new study finds.

"Lacking health insurance was associated with decreased care at each income level. Even though rates of use increase as income increases, uninsured adults are not using their out-of-pocket funds to narrow the gap in use between themselves and insured adults," explained study author Dr. Joseph S. Ross, a primary care internist in the Robert Wood Johnson Clinical Scholars Program at Yale University.

The findings, which came as a surprise to the study authors, also call into question the suitability of recent policy initiatives.

"If the goal is to get people into preventive care and to increase the percentage of people being screened, then we really need to examine the issue of cost-sharing for these services," said Mark Rukavina, executive director of the Access Project, a Boston-based consumer advocacy group focused on the uninsured. "The notion that putting more of the burden for these costs on people will somehow increase the number of people being screened seems foolhardy."

Currently, more than 45 million Americans, representing almost one-fifth of the non-Medicare population -- are without health insurance. The number of Americans without health insurance increased by more than 6 million between 2000 and 2004, largely because of a decline in employer-sponsored coverage, the study stated. One-third of that increase occurred among adults with incomes totaling more than 200 percent of the federal poverty level.

And according to a report released last week, the number of middle-income Americans without health insurance is on the rise: 41 percent of working-age Americans with annual incomes between $20,000 and $40,000 were uninsured for at least part of the past year, up from 28 percent in 2001, analysts found.

Previous research has shown that uninsured adults are less likely to receive preventive services or to get treatment for chronic conditions. Most of that research, however, has focused on lower-income segments.

For this study, which appears in the May 3 issue of the Journal of the American Medical Association, Ross and his team analyzed data on almost 200,000 men and women aged 18 to 64 polled in 2002 on their medical history, health behaviors and use of health-care services.

Incomes were divided into six categories: below $15,000, $15,000 to $25,000 to $35,000, $35,000 to $50,000, $50,000 to $75,000 and greater than $75,000.

Use of different health-care services varied tremendously. For instance, use of cancer-prevention services ranged from 51 percent for colorectal cancer screening to 88 percent for cervical cancer screening. Use of cardiovascular risk reduction services ranged from 38 percent for weight-loss counseling to 81 percent for aspirin use. Diabetes management services ranged from 33 percent for the pneumococcal vaccine to 88 percent for hemoglobin measurement.

The gap between uninsured and insured was roughly the same regardless of the income category. "For none of the groups did income affect use," Ross said. "All of our results were consistent across income."

Although the investigators did not specifically look at reasons for the phenomenon, Ross pointed to a number of possible explanations.

"The one we're most concerned about is that people simply don't believe that these services are sufficiently beneficial, or at least outweigh the costs," he said.

And people may also be afraid of what they might find. "I think there's a fear of opening the Pandora's box," Rukavina said. "The plagues that might fly out of the box are illness, preexisting condition exclusion, and out-of-pocket costs."

This is a problem "both at that point in time when they discover there may be a problem that they have no insurance for and future costs, if their insurance will not cover it because it'd been identified," he continued.

One major question, then, is who should assume more of the costs.

"We think that any type of health-care reform that increases out-of-pocket burden with higher co-payments or higher deductibles or reforms that rely on patients to make decisions to purchase care -- like health savings accounts -- that people are not going to purchase care at the level we would hope to see," Ross said.

Patient education may also help. "People need to understand why doctors are recommending these procedures," Ross added. "If people don't feel it's worth it, Medicare at the very least should be invested in making sure people get these low-cost prevention and chronic care treatments early on."

More information

For more on America's uninsured, head to Families USA.

SOURCES: Joseph S. Ross, M.D., primary care internist, Robert Wood Johnson Clinical Scholars Program, Yale University, New Haven, Conn.; Mark Rukavina, executive director, The Access Project, Boston; May 3, 2006 Journal of the American Medical Association

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