health insurance importance essay

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Institute of Medicine (US) Committee on the Consequences of Uninsurance. Coverage Matters: Insurance and Health Care. Washington (DC): National Academies Press (US); 2001.

Coverage Matters: Insurance and Health Care.

• Hardcopy Version at National Academies Press

1 Why Health Insurance Matters

The Institute of Medicine (IOM) Committee on the Consequences of Uninsurance launches an extended examination of evidence that addresses the importance of health insurance coverage with the publication of this report. Coverage Matters is the first in a series of six reports that will be issued over the next two years documenting the reality and consequences of having an estimated 40 million people in the United States without health insurance coverage. These reports will examine the implications of lacking health insurance for those without it, for their families, for communities in which a substantial number of people are uninsured, and for this country as a whole.

The Committee will look at whether, where, and how the health and financial burdens of having a large uninsured population are felt, taking a broad perspective and a multidisciplinary approach to these questions. To a great extent, the costs and consequences of uninsured and unstably insured populations are hidden and difficult to measure. Financial costs incurred by those without coverage may be covered by payments for the health care of those with insurance or paid by charities and taxpayers, and the health effects may be absorbed by families in the form of diminished physical and psychological well-being, productivity, and income.

The goal of this series of studies is to refocus policy attention on a longstanding problem. Following the longest economic expansion in American history, in 1999, an estimated one out of every six Americans—32 million adults under the age of 65 and more than 10 million children—remains uninsured (Mills, 2000). A better understanding of the consequences of existing policies and health care financing arrangements should reinvigorate discussions of the issue of coverage and better equip us to design and evaluate policy initiatives and proposed reforms intended to address this problem.

The Committee's charge is to communicate to the public and policy makers analytical findings about the meaning of a large uninsured population for individuals, families, and their communities, as well as for society as a whole. Its reports should contribute to the public debate about insurance reforms and health care financing by assessing the theoretical and empirical research in health services, medicine, epidemiology, and economics that bears on the effects of lacking health insurance. It is not within the scope of this project to develop or advocate for a specific set of reforms or policies.

The goal of this first report is to provide background for the findings and conclusions that the Committee will present in subsequent reports about the consequences of uninsurance by including common definitions and an overview of the dynamics of health insurance coverage. This report addresses the extent to which Americans are without coverage, identifies social, economic, and policy factors that contribute to the existence and persistence of an uninsured population in the United States, and reports the probability for members of various population groups of being uninsured. In addition, it introduces a conceptual framework that models how health insurance affects access to health care services and, through such access, affects health and economic well-being. This framework will guide the analysis in succeeding reports in the series and will be modified to address each report's set of topics.

• OBJECTIVES OF HEALTH INSURANCE COVERAGE

The first step in identifying and measuring the consequences of being without health insurance and of high uninsured rates at the community level is to recognize that the purposes and constituencies served by health insurance are multiple and distinct. These purposes include promoting health, obtaining health care for individuals and families, and protecting people financially from exceptional health care costs. Health insurance pools the risks and resources of a large group of people so that each is protected from financially disruptive medical expenses resulting from an illness, accident, or disability. In addition to serving the typical functions of risk insurance, health insurance has developed as a mechanism for financing or pre-paying a variety of health care benefits, including routine preventive services, whose use is neither rare nor unexpected. Despite the fact that a large proportion of persons with health insurance make claims against their coverage every year, health care spending, and thus health insurance payouts, remain concentrated among a relatively small number of claimants, who incur high costs for serious conditions. Ten percent of the population accounts for 70 percent of health care expenditures, a correlation that has remained constant over the past three decades (Berk and Monheit, 2001). Thus health insurance continues to serve the function of spreading risk even as it increasingly finances routine care. From the perspective of health care providers, insurance carried by their patients helps secure a revenue stream, and communities benefit from financially viable and stable health care practitioners and institutions.

Employers offer health benefits both to attract and retain workers and to maintain a productive workforce. Government provides health insurance to populations whom the private market may not serve effectively, such as disabled and elderly persons, and populations whose access to health care is socially valued, such as children and pregnant women.

The ultimate ends of health insurance coverage for the individual and communities, including workplace communities of employees and employers, are improved health outcomes and quality of life. Attributing success in achieving these goals to health insurance alone presents a challenge because isolating the relative contribution of different determinants of individual and population health requires a complex analysis. Over the past quarter of a century, the importance of health insurance has grown, as clinical medicine has become increasingly sophisticated, technological advances have become more commonplace, and the range of therapeutic interventions (and their costs) has expanded rapidly. As a society, we invest heavily in health insurance through direct personal expenditures, forgone wages, and tax policy. Health insurance in the United States has developed as a common but not universal component of the employment contract. Employees rank health insurance first by far in importance among all the benefits offered in the workplace (Salisbury, 2001). Although there have been sizable investments of personal and public funds to provide health insurance, many people still have no coverage.

• MYTHS AND REALITIES ABOUT HEALTH INSURANCE

Despite extensive reporting of survey findings and health care research results, the general public remains confused and misinformed about Americans without health insurance and the implications of lacking coverage. This section presents basic information about health insurance and who lacks it in the context of several pervasive popular myths. Without question, the complexity of American health care financing mechanisms and the wealth of sources of information add to the public's confusion and skepticism about health insurance statistics and their interpretation. This report and those that will follow aim to distill and present in readily understandable terms the extensive research that bears on questions of health insurance coverage and its importance.

Myth: Uninsured people get health care when they really need it. Fifty-seven percent of Americans polled in 1999 believed that those without health insurance are “able to get the care they need from doctors and hospitals” (Blendon et al., 1999, p.207). In 1993, when national attention was focused on the problems of the uninsured and on pending health care legislation, just 43 percent of those polled held this belief (Blendon et al., 1999).

Reality: The uninsured are much more likely to forgo needed care (Schoen and DesRoches, 2000). They also receive fewer preventive services and are less likely to have regular care for chronic conditions such as hypertension and diabetes. Chronic diseases can lead to expensive and disabling complications if they are not well managed (Lurie et al., 1984; Lurie et al., 1986; Ayanian et al., 2000). One national survey asked more than 3,400 adults about 15 highly serious or morbid conditions. Of those reporting any such symptoms (16 percent of those surveyed), and with adjustment for demographic and economic characteristics, health status, and a regular source of care, 1 an uninsured person was far less likely than someone with insurance to receive care for the reported condition (odds ratio =0.43) (Baker et al., 2000). Additional evidence is presented later in this chapter in the discussion of insurance and access to health care.

Myth: People without health insurance are young and healthy and choose to go without coverage. Almost half (43 percent) of those surveyed in 2000 believed that people without health insurance are more likely to have health problems than people with insurance. About as many (47 percent) thought the likelihood of health problems is about the same for insured and uninsured people (NewsHour-Kaiser, 2000). Voters and policy makers in focus group discussions characterize those without insurance as young people who have the opportunity to be covered and feel they do not need it (Porter Novelli, 2001).

Reality: Compared to those with at least some private coverage, the uninsured are less likely to report being in excellent or very good health (Agency for Healthcare Research and Quality, 2001). In contrast, people reporting excellent or very good health are more likely to be insured. Among those under age 65 who are in fair or poor health, nearly one in five lacks health insurance (Rhoades and Chu, 2000). Of young adults (ages 19–34 years) in poor health, 16 percent are uninsured and 27 percent of those reporting fair health status are uninsured ( Figure 1.1 ) (Agency for Healthcare Research and Quality, 2001).

Probability of being uninsured for young adults, ages 19 to 34 years, by self-reported health status, 1999. SOURCE: Center for Cost and Financing Studies, Agency for Healthcare Research and Quality, based on MEPS data.

Young adults between 19 and 34 are far more likely to lack health insurance than any other age group. This is chiefly because they are less often eligible for employment-based insurance due to the nature of their job or their short tenure in it. They are also more likely than older adults to be in excellent or very good health and consequently may forgo the cost of workplace coverage if it is offered. Turning down a ‘workplace offer is not, however, a significant factor in explaining their lack of coverage. Younger workers accept workplace offers of coverage more often than not, and only 4 percent of all workers between 18 and 44 years of age, roughly 3 million, are uninsured after turning down workplace insurance (Custer and Ketsche, 2000b). Another 11 million uninsured workers between the ages of 18 and 44 (15 percent) hold jobs that do not include an offer of coverage.

The perception that people without insurance have better-than-average health follows from confusing the relatively young age profile of the uninsured with the better health, on average, of younger persons. This obscures the link between health status and health insurance. For those without access to workplace health insurance, poor health is a potential barrier to purchasing nongroup coverage because such coverage may be highly priced, exclude preexisting conditions, or be simply unavailable. Older women (55–64 years) in the work force are especially at risk of being uninsured for this reason: 23 percent of those in good, fair, or poor health have no coverage compared to 10 percent of those in excellent or very good health (Monheit et al., 2001).

Myth: The number of uninsured Americans is not particularly large and has not changed in recent years. Seven out of ten respondents in a nationally representative survey thought that fewer Americans lacked health insurance than actually do (Fronstin, 1998). Roughly half (47 percent) believed that the number of people without health insurance decreased or remained constant over the latter half of the last decade (Blendon et al., 1999).

Reality: During 1999, an estimated 42 million people in the United States lacked health insurance coverage (Mills, 2000). This number represents about 15 percent of a total population of 274 million persons. According to Census Bureau statistics, the number of Americans under age 65 without health insurance grew from 39 million (17 percent of the population under age 65) in 1994 to 44 million (18 percent) in 1998, before falling to 42 million (17 percent) in 1999 (Fronstin, 2000d). This drop of almost 2 million in the number of people ‘without insurance (a reduction of about 4 percent) is certainly a positive change. With a softer economy in 2000 the latest reported gains in insurance coverage may not continue (Fronstin, 2001). The decline in the number of uninsured will not continue if the economy remains slow and health care costs continue to outpace inflation. Due to the lag in measurement and reporting, however, the Census Bureau estimate of health insurance coverage for 2000 may show a further decline in the uninsured rate. This is because the data were collected for a period of strong economic performance.

Of the estimated 42 million people who were uninsured, all but about 420,000 (about 1 percent) were under 65 years of age, the age at which most Americans become eligible for Medicare ; 2 32 million were adults between ages 18 and 65, about 19 percent of all adults in this age group; and 10 million were children under 18 years of age, about 13.9 percent of all children (Mills, 2000). Throughout this report, the discussion focuses on these uninsured working-age adults and children.

These estimates of the number of persons uninsured are generated from the annual March Supplement to the Current Population Survey (CPS), conducted by the Census Bureau. Unless otherwise noted, national estimates of people without health insurance and proportions of the population with different kinds of coverage are based on the CPS, the most widely used source of estimates of insurance coverage and uninsurance rates. Seven different governmentally and privately sponsored surveys can, however, be used to make nationally representative estimates of the number of people without health insurance. These surveys and the estimates they yield are described briefly in Table B.1 in Appendix B . These surveys differ in size and sampling methods, the questions that are asked about insurance coverage, and the time period over which insurance coverage or uninsurance is measured (Lewis et al., 1998, Fronstin, 2000a). Each survey produces a different estimate of the number of Americans without insurance. The estimates range from 32 million (e.g., Medical Expenditure Panel Survey, 1996, uninsured throughout the year) to 42 million (CPS, 1999, uninsured throughout the year). 3

The CPS has been criticized for producing estimates of persons uninsured throughout the year that are too high and probably reflect periods without insurance of less than a full year as well as underreporting of Medicaid coverage (Swartz, 1986; Lewis et al., 1998; Fronstin, 2000a). The Census Bureau has recently revised its survey questionnaire to include an additional question verifying that the respondent means to report lack of coverage over the entire previous year (see Appendix B for further explanation). Still, the CPS is especially useful because it produces annual estimates relatively quickly, reporting the previous year's insurance coverage estimates each September, and because it is the basis for a consistent set of estimates for more than 20 years, allowing for analysis of trends in coverage over time. For these reasons, as well as the extensive use of the CPS in other studies of insurance coverage that are presented in this report, we rely on CPS estimates, with limitations noted. The Committee finds the variation among estimates of the number of persons uninsured produced by the different surveys less critical to its analysis than the order of magnitude of the range of estimates that these surveys yield.

The estimate of the number of uninsured people expands when a population's insurance status is tracked for several years. Over a three-year period beginning early in 1993, 72 million people, 29 percent of the U.S. population, were without coverage for at least one month. Within a single year (1994), 53 million people experienced at least a month without coverage (Bennefield, 1998a).

Myth: Most people who lack health insurance are in nonworking families. An April 2000 national telephone survey by the NewsHour with Jim Lehrer-Kaiser Family Foundation found that 57 percent of the adults polled believed that most people without health insurance were unemployed or from families with unemployed adults (News Hour—Kaiser, 2000). Other surveys report comparable findings (Blendon et al., 1999; Wirthlin Worldwide, 2001).

Reality: More than 80 percent of uninsured children and adults under the age of 65 live in working families. Six out of every ten uninsured adults are themselves employed. Although working does improve the likelihood that one and one's family members will have insurance, it is not a guarantee. Even members of families with two full-time wage earners have almost a one-in-ten chance of being uninsured (9.1 percent uninsured rate) (Hoffman and Pohl, 2000). See Chapter 3 , especially Figures 3.1 and 3.2 , for further details.

Myth: New immigrants account for a substantial proportion of people without health insurance. One analysis has attributed a significant portion of the recent growth in the size of the U.S. uninsured population to immigrants who arrived in the country between 1994 and 1998 (Camarota and Edwards, 2000).

Reality: Recent immigrants (those who came to the United States within the past four years) do have a high rate of being uninsured (46 percent), but they and their children account for just 6 percent of those without insurance nationally (Holahan et al., 2001). In fact, there has been a net decrease in the number of recently arrived immigrants since 1994 (Holahan et al., 2001). Overall, noncitizens account for fewer than one in five uninsured persons (Mills, 2000).

Myths and Policy Making

Popular confusion about the facts of health insurance coverage and its importance can hamper effective policy making, as can policy makers' uncertainty about the interpretation of coverage trends and consequences. This report and those that will follow aim to provide reliable information, useful to both the public and policy leaders—legislators, employers, program managers—as they meet the ongoing challenges of financing health care.

• THE COMMITTEE'S ANALYTIC STRATEGY

Measuring Impacts of Coverage

Health insurance coverage is a key element in most models that depict access to health care. The relationship between health insurance and access to care is well established, as documented later in this chapter. Although the relationship between health insurance and health outcomes is neither direct nor simple, an extensive clinical and health services research literature links health insurance coverage to improved access to care, better quality, and improved personal and population health status. The Committee's conceptual framework for considering the extent and nature of these and additional effects of health insurance builds selectively upon the most widely used behavioral model of access to health services (Andersen, 1995; Andersen and Davidson 2001). The framework focuses primarily on the economic, financial, and coverage-related factors that facilitate the use of health care services. The Committee uses the framework in this introductory report to conceptualize various effects of health insurance and to provide an overview of the subsequent analyses in future reports (see Figure ES.2 and Appendix A for a further description of this model).

The Committee will use this conceptual model to identify, organize, and assess the evidence regarding important consequences of uninsurance, each of which will be the subject of a future report: individual health outcomes, family well-being, community impacts, and economic costs for society as a whole. Figure 1.2 depicts the relationship among the topics of the Committee's reports in terms of a series of overlapping circles. For example, the second report, on personal health outcomes for uninsured adults, is represented by the innermost circle of the figure, while the third report, on family well-being, encompasses the subjects of the second report but emphasizes a different unit of analysis, namely, the family. The sixth report in the series will present information about strategies and initiatives undertaken locally, statewide, or nationally to address the lack of insurance and its adverse impacts. Each of these planned reports is described briefly in Chapter 4 .

Levels of analysis for examining the effects of uninsurance.

Scope of This Report

This discussion of health insurance coverage focuses primarily on the U.S. population under age 65 because virtually all Americans 65 and older have Medicare or other public coverage. Furthermore, it focuses specifically on those without any health insurance for any length of time. While the effects of lacking health insurance on access to care and thus potentially on health may not be apparent for those who are uninsured only briefly, even short periods without insurance entail a measure of financial risk to self and family of incurring high expenses for health care.

The Committee does not attempt to address the condition of “underinsurance.” By the “underinsured” is meant individuals or families whose health insurance policy or benefits plan offers less than adequate coverage. Most people would consider themselves underinsured if their health plan required extensive out-of-pocket payments in the form of deductibles, coinsurance or copayments, or maximum benefit limits. Many policies also exclude specific services such as mental health treatment, long-term care, or prescription drugs. The problems faced by the under insured are in some respects similar to those faced by the uninsured, although they are generally less severe. Un insurance and under insurance, however, involve distinctly different policy issues, and the strategies for addressing them may differ. Throughout this study and the five reports to follow, the main focus is on persons with no health insurance and thus no assistance in paying for health care beyond what is available through charity and safety net institutions.

• INSURANCE AND ACCESS TO HEALTH CARE

For individuals and families, health insurance both enhances access to health services and offers financial protection against high expenses that are relatively unlikely to be incurred as well as those that are more modest but are still not affordable to some. Health insurance is a powerful factor affecting receipt of care because both patients and physicians respond to the out-of-pocket price of services. Health insurance, however, is neither necessary nor sufficient to gain access to medical services. Nonetheless, the independent and direct effect of health insurance coverage on access to health services is well established. This section documents that research literature and presents the Committee's findings regarding access to care.

Subsequent Committee reports will build on this finding and evaluate evidence for the further relationship between insurance coverage and health outcomes. Appendix A describes and depicts schematically the Committee's conceptual model of this complex relationship, which is affected by a variety of personal, economic, and social factors and health care processes that are in turn subject to many influences.

Health Insurance Facilitates Access to Care

Many people who lack health insurance will forgo the care they need until their condition becomes intolerable. Others will obtain the health care they need even without health insurance, by paying for it out of pocket or seeking it from providers who offer care free or at highly subsidized rates. For still others, health insurance alone does not ensure receipt of care because of other nonfinancial barriers, such as a lack of health care providers in their community, limited access to transportation, illiteracy, or linguistic and cultural differences. Nonetheless, health insurance remains a key factor in assuring access to health care.

Formal research about uninsured populations in the United States dates to the late 1920s and early 1930s when the Committee on the Cost of Medical Care produced a series of reports about financing physician office visits and hospitalizations. This issue became salient as the numbers of medically indigent climbed during the Great Depression. With the rise of commercial insurers and the decline of community rating offered by Blue Cross-Blue Shield and other nonprofit insurers in the 1950s, new studies of individual and family health expenditures were co-sponsored by the University of Chicago and the Health Information Foundation. These studies became the factual basis for legislation that was enacted as the Medicare and Medicaid amendments to the Social Security Act in 1965.

Since the enactment of Medicare and Medicaid , health services research on uninsured populations has been sponsored federally and privately, at increasing levels of support over time and using new survey tools and data sets (Somers and Somers, 1961; Numbers, 1979; Starr, 1982; Andersen and Anderson, 1999). The Census Bureau started collecting detailed information about health insurance in the latter half of the 1970s and the National Center for Health Services Research, a predecessor to AHRQ, conducted the National Medical Care Expenditure Survey (NMCES) in 1977, followed by the National Medical Expenditure Survey (NMES) in 1987 and AHRQ's Medical Expenditure Panel Survey (MEPS), launched and conducted annually since 1996. A summary of the major surveys collecting health insurance and utilization information is presented in Appendix B .

Population-based surveys have been used to examine access to health services by measuring components of primary care, such as number of physician visits and immunization rates, sites of care (e.g., physician office, hospital outpatient department, clinic), barriers to care (e.g., inability to pay), and unmet health needs (e.g., health status, inability to obtain care when needed) (Andersen and Aday, 1978; Aday et al., 1984; Lurie et al., 1984; Monheit et al., 1985; Lurie et al., 1986; Hafner-Eaton, 1993; Newacheck et al., 1993; Himmelstein and Woolhandler, 1995; Sox et al., 1998; Hsia et al., 2000; Kasper et al., 2000). The likelihood of having any physician visit within a year, the number of visits annually, and having a regular source of care are well established measures of access. Empirical studies consistently support the link between access to care and improved health outcomes (Bindman et al., 1995; Starfield, 1995).

Having a regular source of care can be considered a predictor of access, rather than a direct measure of it, when health outcomes are themselves used as access indicators. This extension of the notion of access measurement was made by the IOM Committee on Monitoring Access to Personal Health Care Services (Millman, 1993, p.33):

“[T]he committee defined access as follows: the timely use of personal health services to achieve the best possible health outcomes. Importantly, this definition relies on both the use of health services and health outcomes to provide yardsticks for judging whether access has been achieved.”

Thus, in Access to Health Care in America, the earlier IOM committee incorporated health outcomes into the definition of access. In this first report of the Committee on the Consequences of Uninsurance , consideration of the relationship between health insurance and access is limited to well established findings regarding process measures of access. The next report, which will examine health outcomes for the uninsured, will evaluate clinical and epidemiological research evidence in terms of the more demanding concept of realized access to health care.

The likelihood that those without health insurance lack a regular source of care has increased substantially since 1977. In 1996, people without insurance were 2.5 times more likely to lack a regular source of care than were the insured (Zuvekas and Weinick, 1999; Weinick et al., 2000). Children without insurance were three times as likely as children with Medicaid coverage to have no regular source of care (15 percent versus 5 percent), and uninsured adults were more than three times as likely as either privately or publicly insured adults to lack a regular source of care (35 percent versus 11 percent) (Haley and Zuckerman, 2000).

The benefits for children of having health insurance and a regular source of care, in terms of routine physician visits and appropriate preventive care, are well documented (Lave et al., 1998; Newacheck et al., 1998; Haley and Zuckerman, 2000). However, the impact of parents' health and health insurance on the well-being of their children has received attention only recently. Whether or not parents are insured appears to affect whether or not their children receive care— as well as how much care—even if the children themselves have coverage (Hanson, 1998). The health of parents can affect their ability to care for their children and the level of family stress. Worrying about their children's access to care is itself a source of stress for parents.

Uninsured adults are less likely to receive health services, even for certain serious conditions. In a study described earlier (Baker et al., 2000), even after adjusting for differences in age, sex, income, and health status, uninsured people were less than half as likely as insured persons to receive care for a condition that physicians deemed highly serious and requiring medical attention. People without insurance are also less likely than people with insurance to receive preventive services and appropriate routine care for chronic conditions, even as the importance of preventive care and the prevalence of chronic disease become more prominent elements within health care (Hafner-Eaton, 1993; Ayanian et al., 2000; Institute of Medicine, 2001). Finally, those who lack health insurance are more likely to be hospitalized for conditions that might have been avoided with timely ambulatory care (Weissman et al., 1992; Kozak et al., 2001).

The level of out-of-pocket costs for care has been demonstrated in randomized trials, natural experiments, and observational studies to have substantial effects on the use of health care services (Newhouse et al., 1993; Zweifel and Manning, 2000). Table 1.1 gives a sense of the magnitude of these costs. Uninsured patients may be charged more than patients with coverage, who benefit from discounts negotiated by their insurer, which amplifies the financial impact of lacking coverage (Wielawski, 2000; Kolata, 2001).

Illustrative Charges to Patients, Insured and Uninsured, 1999 (in dollars).

Differential Access to Care for the Uninsured

Not only do persons without insurance receive less care, but the providers who serve them differ systematically from those who treat insured patients. Public hospitals, health departments, and health clinics (e.g., community, migrant, or rural health centers) are more likely than other providers to serve uninsured persons, two-thirds of whom are members of lower-income families (annual income below 200 percent of the federal poverty level [ FPL ]: $33,400 for a family of four in 1999). These institutions generally receive public funding to support the provision of free or reduced fee care to those who cannot afford to pay private fees. They serve as “core safety-net providers,” with two distinguishing characteristics:

“(1) either by legal mandate or explicitly adopted mission they maintain an “open door,” offering access to services for patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid , and other vulnerable patients” (Institute of Medicine, 2000).

The IOM report on the safety net also stressed the diversity of local safety-net providers and services across states, communities, and geographic regions. In rural areas, for instance, the mix of safety-net providers tends to feature private physicians and health centers or clinics, whereas urban areas are more likely to be served by teaching hospitals (Schur and Franco, 1999).

In addition to those providers whose patient populations include substantial proportions of uninsured persons, in the aggregate, private physicians, community hospitals, and teaching hospitals affiliated with academic health centers provide significant amounts of care to uninsured patients (Cunningham and Tu, 1997; Mann et al., 1997; Institute of Medicine, 2000). Nationally representative surveys show that between two-thirds and three-quarters of physicians report providing some charity care, accounting for about 5 percent of their case load on average (Foreman, 1992; Cunningham, 1999b).

The wide geographic variation in the organization, financing, and delivery of health services contributes to the scarcity of quantitative information about services for uninsured people. Compared with insured persons, greater numbers of uninsured persons obtain care from hospitals and clinics or health centers than from office-based physicians, and are less likely to identify a person, rather than a facility, as their usual source of care (Shi, 2000a). Uninsured patients are less than half as likely as insured patients to report that a physician's office is their usual source of care (about one-third of all uninsured patients compared with about two-thirds of the general population) (Cunningham and Whitmore, 1998).

Hospital emergency departments or outpatient departments serve as the regular source of care for one out of every six uninsured patients that report having a regular source of care (Weinick et al., 1997). A substantial proportion of emergency department visits is for nonurgent conditions (Pane et al., 1991; Grumbach et al., 1993; Baker et al., 1994; Zimmerman et al., 1996). Because hospital emergency departments are legally required to assess and stabilize all patients with any medical condition without regard for ability to pay, they are the only providers who cannot turn uninsured patients away for lack of a source of payment. 4 Although emergency departments are portrayed as a costly and inappropriate site of primary care services, many uninsured patients seek care in emergency departments because they are sent there by other health care providers or have nowhere else to go. Emergency care specialists argue that the nation's emergency departments not only serve as providers of last resort but are a critical entry point into the health care system (O'Brien et al., 1999).

• WHAT FOLLOWS

Three chapters follow in this report. Chapter 2 provides an overview of how employment-based health insurance, public programs and individual insurance policies operate and interact to provide extensive but incomplete coverage of the U.S. population. This includes a review of historical trends and public policies affecting both public and private insurance, a discussion of the interactions among the different types of insurance, and an examination of why people move from one program to another or end up with no coverage.

Chapter 3 synthesizes existing information to arrive at a composite description of the uninsured: What characteristics do people without coverage often share? Where do the uninsured live? The chapter also presents information about the risk of being or becoming uninsured: How does the chance of being uninsured change depending on selected characteristics, such as racial and ethnic identity, rural or urban residency, and age? What are the probabilities for specific populations, such as racial and ethnic minorities, rural residents, and older working-age persons, of being uninsured? How does the chance of being uninsured change over a lifetime?

In addition to characterizing the likelihood of being uninsured in terms of a single dimension, such as gender, age, race, work status, or geographic region, Chapter 3 also presents the results of multivariate analyses that offer a more informative depiction of the factors that contribute to the chances of being uninsured.

Finally, in Chapter 4 the Committee presents the research agenda for its overall project and previews the five future reports.

In the United States, health insurance is a voluntary matter, yet many people are involuntarily without coverage. There is no guarantee for most people under the age of 65 that they will be eligible for or able to afford to purchase or retain health insurance.

• Almost seven out of every ten Americans * under age 65 years are covered by employment-based health insurance, either from their job or through a parent or spouse. Three quarters of workers are offered health insurance by their employers, and most decide to purchase or take up the offer of coverage. Of the 17 percent of workers who decline an employer's offer, about a quarter, or 4 percent of workers overall, remain uninsured.
• Individually purchased policies and public insurance (primarily Medicaid ) together cover one out of five persons under age 65.* Both have limitations. Poor health status or low income may preclude the purchase of an affordable individual policy. The combination of strict eligibility requirements and complex enrollment procedures makes public coverage often difficult to obtain and even more difficult to maintain over time.
• A change in insurance premium or terms, as well as changes in income, health, marital status, terms of employment, or public policies, can trigger a loss or gain of health insurance coverage. For about one-third of the uninsured population, being without coverage is a temporary or one-time interruption of coverage, and the median duration of a period without insurance is between 5 and 6 months. Uninsured persons in low-income families and those with less education experience longer periods without coverage, on average, than their higher income and more educated counterparts.
• Insurance industry underwriting practices, the costs of health services, and the patchwork of public policies regarding insurance coverage all contribute to the economic pressures on employers, insurers, and government programs offering health insurance. Small firms are especially likely to face high costs. Workers who take up an employer's offer of a subsidized health benefit typically pay directly between one-quarter and one-third of the total cost of their insurance premium, in addition to paying deductibles, copayments, and the costs of health services that are not covered or are covered only in part by their health plan. For families earning less than 200 percent of the federal poverty level, these expenses can exceed 10 percent of their annual income.
• Since the mid-1970s, growth in the cost of health insurance has outpaced the rise in real income, creating a gap in purchasing ability that has added roughly one million persons to the ranks of the uninsured each year. Despite the economic prosperity of recent years, between 1998 and 1999 there was only a slight drop in the numbers and proportion of uninsured Americans. Through the early 1990s, the rising uninsured rate reflected a decline in employment-based coverage. Since the mid-1990s, increases in employment-based coverage have been offset by steady or declining rates of public and individually purchased coverage.

Altogether, about 83 percent of the nonelderly population is covered by employment-based, individual and public plans. Some people report more than one source of coverage over the course of a year.

“Regular source of care” is defined as the place or provider from which one usually seeks care or advice about health care. A regular source of care may be a physician's office, a clinic, a health plan facility or a hospital emergency room or outpatient clinic. Optimally, one's regular source of care provides continuity of attention, facilitates access to appropriate services, and maintains records.

Medicare , the federal insurance program for the elderly, disabled, and those with end-stage renal disease, provides almost universal coverage for hospital care for those over age 65. A small fraction of the elderly do not qualify for the program because they do not have sufficient Social Security work credits. The clergy and other religious workers comprise the largest single category of people without ties to Social Security and Medicare.

In 1996, the CPS estimate of the number of nonelderly persons uninsured was 41 million (Fronstin, 2000a).

The federal Emergency Medical Treatment and Active Labor Act, part of the Consolidated Omnibus Budget Reconciliation Act of 1985, requires hospital emergency rooms to assess and stabilize all patients with a life- or limb-threatening or emergency medical condition or those who are about to give birth. Hospitals are not required to provide continuing care after the patient has been stabilized and transferred or released. No federal funds directly support this mandate.

• Cite this Page Institute of Medicine (US) Committee on the Consequences of Uninsurance. Coverage Matters: Insurance and Health Care. Washington (DC): National Academies Press (US); 2001. 1, Why Health Insurance Matters.
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Health Insurance is a Family Matter (2002)

Chapter: 7 conclusions, 7 conclusions.

The Committee’s overarching conclusion is that insurance coverage within a family concerns and may affect the entire family unit. The lack of insurance of any family member has the potential to affect the financial and emotional well-being of all members of the family. This suggests that we focus not only on the more than 38 million uninsured adults and children in the United States, but also on the 17 million families in which some or all members are uninsured. 1

A FAMILY PERSPECTIVE

Of the 85 million families in the United States, 17 million have one or more members who lack health insurance. Narrowing the focus to the roughly 38 million families with children, in 3.2 million of these families all members lack insurance and in an additional 4.3 million families some but not all members are uninsured (see Chapter 2, Table 2.1 ). Together these uninsured families with children account for about one-fifth of all families with children. Among married, childless couples, an additional 3.7 million family units have one or both members uninsured. More than 38 million uninsured people live in the 11.1 million family units mentioned above, with relatives other than their own children under age 18, with people other than conventionally recognized kin, or alone. Because of family relationships—financial responsibilities, psychosocial ties, and traditional child rearing obligations—an uninsured individual may affect the lives of other immediate family members, even if they have coverage. Thus, the consequences of not

having health insurance may intimately touch the lives of more than 58 million of the 276.5 million people in this country.

FINANCIAL AND HEALTH CONSEQUENCES FOR FAMILIES

Many of these 58 million feel the impact of living with uninsured family members as merely an insecurity or worry about the possibility of a very large health-related expense. Fortunately, very serious and expensive illnesses and accidents occur relatively rarely, although chronic and expensive conditions are more common. Uninsured families do have reason to worry. More than 15 percent of families with all members uninsured for the full year experience health expenditures that exceed 5 percent of their family income in a year compared with 9 percent of families in which all members are either privately insured or covered by Medicaid. Expenditures are also higher for families whose members are uninsured for the full year than for those who may have lacked coverage for a shorter period. Because families with at least one uninsured member tend to have lower incomes than do fully insured families, along with very few assets, they generally have fewer financial resources to help cope with these higher expenses. This may financially destabilize the entire family. The Committee recognizes, however, that high out-of-pocket medical bills can be damaging to families at almost any income level, whether or not they are insured.

For uninsured families, what is more common than ruinous health costs is the likelihood that they will go without needed care. Although uninsured people tend to have poorer health status than otherwise comparable insured people, they are less likely to visit a physician, fill prescriptions, and obtain preventive care and other services. Chapter 6 of this report presents strong evidence that insured children have better access to and use more health care services than do uninsured children. Uninsured children are less likely to receive the routine medical attention that is considered necessary for quality preventive care than are insured children. Low-income, minority, non-citizen, or uninsured children consistently have worse access and use than do children without those characteristics. Uninsured adolescents are more likely than those with insurance to have no regular source of care, fewer visits, and unmet health needs. Similarly, uninsured children with special health care needs, whose medical conditions require significantly more than routine well-child care, also have less access to a usual source of care, are less likely to have seen a doctor in the past year, and are less able to get needed medical, dental, prescription, and other care compared to children with special health care needs who do have insurance.

Many of the health and developmental implications of the reduced access to and use of services by uninsured children may not become apparent on a population-wide basis, at least not for many years, because most children tend to be healthy and have many fewer chronic conditions than their elders. Nonetheless, studies demonstrate that parents delay seeking care for their uninsured children

until the symptoms are more severe. These delays may result in unnecessary hospitalizations for conditions that could have been treated on an ambulatory basis and, in some cases, place uninsured children at a higher risk of premature death. If left untreated, some of the common childhood illnesses that can be detected and treated with routine care can also have long-term negative impacts on children’s development, including middle-ear infections, asthma, and iron deficiency. To the extent that timely and appropriate medical care might ameliorate or even prevent these conditions, insurance contributes to better future functioning and life chances for children. Further, provision of preventive care to children can have beneficial long-term effects that extend beyond health, so that society can reap the rewards in the future. The Committee recognizes, however, that there are many factors in addition to medical care that influence children’s health and development.

IMPLICATIONS OF PARENTAL COVERAGE

The Committee’s second report, Care Without Coverage: Too Little, Too Late, shows that the 30 million adults without coverage, many of whom are parents, are less likely to receive appropriate, timely care, particularly for chronic illnesses and certain life-threatening conditions, such as cancer, than are insured adults. Health policy researchers and health care professionals understand the financial and health risks of having family members without insurance. The public also appreciates these risks by showing a strong preference for insuring their families, when given a realistic and affordable option for family coverage. The Committee’s analyses in this report reveal another, more insidious and subtle consequence of uninsurance, namely that if a parent is uninsured, the children in the family may be less likely to get the medical care they need, even if the children have coverage.

Because children depend upon their parents and guardians as decision makers as well as caregivers, parents’ experiences with the health care system and their beliefs about health care are important. Parents’ ability to negotiate that system on behalf of their children affects how children benefit from their insurance eligibility and coverage. In Chapter 5 , the Committee shows that parents’ own use of health care, including whether they have a usual source of care and are connected to the health care system, are powerful predictors of their children’s use of services. Compared to insured adults, uninsured adults are more likely to have no doctor visit in the previous year, to use fewer medical services, and to have negative experiences when they finally obtain health care. The evidence suggests that children of uninsured parents may be less likely to get the full benefit of their own coverage than are children whose parents are also insured.

Not only may parental coverage be an important determinant of children’s access to care, it also can affect the parents’ health. The mental and physical health of parents plays an important role in child well-being. Being in poor physical or mental health, which is more likely for those of low income and those without insurance, has a bearing on a parent’s child rearing practices and ability to cope

with the stresses of raising a family. The physical and emotional health and development of their children may suffer as a result of parents’ poor health.

A key example of a parent’s health affecting that of the child can be seen during pregnancy. Providing public health insurance to previously uninsured pregnant women increases the use of prenatal care but not to the level seen with privately insured women. Uninsured women and their newborns receive less prenatal care and fewer expensive perinatal services than do insured women. Uninsured newborns are more likely to have adverse outcomes than are their insured counterparts. The evidence to date on whether expanding coverage improves an outcome such as low birthweight is not definitive, however.

POPULATIONS AT RISK

Families having some or all members with no insurance for extended periods are at greater risk of adverse consequences than are those with brief gaps in coverage. The Committee has shown that families with members uninsured for long periods are more likely to incur substantial health care costs for services and to suffer adverse consequences to health. These risks have added significance because of the types of families most likely to have some or all members uninsured.

The families in which some or all members lack insurance disproportionately are low income, single parent, immigrant, and racial and ethnic minorities. They face multiple barriers to care—of culture, education, and language—in addition to lack of financial means. The percentage of families with children in which no members are insured increases as family income declines. Also, minority population families are more likely to be wholly uninsured or have some members without coverage than are other families. The uninsured rate for immigrants and naturalized citizens has been significantly higher than that of U.S.-born residents.

In addition, there are families more likely to suffer negative consequences of having uninsured members, even though they are relatively more likely to have insurance than are the populations above. These families have members in late middle age, approaching retirement. Their increased risk comes from the fact that their health care needs and costs are likely to be higher than those of younger families. The limitations of employment-based insurance and the frequency of retirement before the age of Medicare eligibility put both the early retiree and the dependent spouse in danger of losing coverage. In fact, some health conditions and certain chronic illnesses can precipitate early retirements, either for the worker to care for an ill spouse or because work is no longer possible for the ill member of the family.

A PUBLIC POLICY PERSPECTIVE

Public policies that affect opportunities for and the structure of health insurance coverage have great societal significance, given the harmful impacts on families as well as on individuals that are associated with the lack of insurance.

What can the Committee’s analysis in this report on families contribute to policy makers dealing with issues related to health insurance coverage?

In its previous report, the Committee highlighted the importance of ease of access to a regular and continuing relationship with a health care professional, which is associated with better health outcomes and is usually facilitated through insurance. In this study the evidence demonstrates that uninsured children are less likely than insured children to have a usual source of health care or a regular physician. For children, gaps in coverage are associated with health access and use that resemble those of chronically uninsured children. There are several limitations of current insurance arrangements that hinder ease of access to a usual source of care for families. There is also evidence that expanding public programs to previously uninsured children brings a significant increase in access to and use of health services.

The nature of private and public health insurance means that transitions over the course of family life—job changes, divorce, retirement, death of an insured member—often disrupt health coverage for those who had it. Eligibility for private insurance may exclude some family members because they do not meet specific legal definitions or because a child ages beyond a specified limit. Definitions of eligibility and requirements for re-enrollment in public programs may also contribute to gaps in coverage. While some rules for insurance programs are unavoidable, from the family perspective, some of these definitions and limits may cause disruption and discontinuities that are counterproductive to promoting healthy families. Policy efforts targeted at expanding the limits and definitions of insurance eligibility and smoothing the discontinuities will be examined further in the Committee’s sixth report.

Approximately 20 million children are currently covered by Medicaid and the State Children’s Health Insurance Program (SCHIP) program expansions. Nonetheless, almost 5 million children who are potentially eligible for these programs remain uninsured (Urban Institute, 2002a). Recent efforts to simplify the application and re-enrollment processes in many states have contributed to increased coverage. The Committee’s evidence-based review shows clearly that lack of insurance for children reduces access, appropriate utilization, and some health outcomes. In addition, lack of coverage for parents means they are less likely to obtain care or to have positive experiences with the health care system and that this is likely to have a negative impact on their seeking care for their children.

The perspective of this report on coverage of families also highlights the importance of the interdependence of individuals within families, the shared health and economic consequences of uninsurance, and the importance of stronger efforts to view the family in its entirety and to consider health insurance for the whole family. Among private, employment-based insurance plans there has been a small but promising trend to expand the definition of family to include both partners in a relationship, for example, unmarried couples, both mixed sex and same sex. This development increases the opportunity for some adults to receive coverage as dependents.

While enrollment in the employment-based insurance market grew during the strong economy of the past decade, continuing growth in enrollment seems less promising now. Recent economic trends relating to recession, a soft labor market, an increasing rate of health cost inflation, and resulting premium increases all support the expectation that employers will be shifting more costs onto their employees. Higher premiums, copayments, and deductibles are likely to result in fewer employees deciding they can afford to take up the offer of coverage for themselves and their families. There are also indications that the trend for employers to reduce the amount of health insurance they offer to their retirees will continue.

The Committee notes the recent policy discussions regarding subsidizing Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage for workers who lose their jobs under particular circumstances. 1 The discussions recognize the value of health insurance and the need to make it more affordable for workers and their families to keep. Although many workers cannot benefit from COBRA protections (e.g., those whose jobs do not offer health benefits), it could help some workers and their families through some employment-related transitions if it were affordable. The limited real opportunities for coverage available to uninsured workers has recently become more widely understood by the public, but political solutions are yet to be found.

The outlook for continuing expansions of Medicaid and SCHIP may also be affected by the recession. Eligibility for Medicaid coverage is likely to grow as unemployment rises. Most state budgets are feeling the constraints of lower-than-forecasted revenues and some may be tempted to cut back on public coverage rather than to expand it (Kaiser, 2001a). Even without formal changes in eligibility, there has been discussion in some states to stop aggressive campaigns to enroll currently eligible children in their SCHIP program because the campaigns are perceived as sufficiently successful that they are increasing program costs. Such cutbacks might mean that fewer of the millions of eligible children will enroll than might have done.

The Committee’s final report will examine in further depth both the implications for public policy of the consequences of uninsurance on families and the impact of various programs and policies designed to counteract the negative effects.

Health Insurance is a Family Matter is the third of a series of six reports on the problems of uninsurance in the United Sates and addresses the impact on the family of not having health insurance. The book demonstrates that having one or more uninsured members in a family can have adverse consequences for everyone in the household and that the financial, physical, and emotional well—being of all members of a family may be adversely affected if any family member lacks coverage. It concludes with the finding that uninsured children have worse access to and use fewer health care services than children with insurance, including important preventive services that can have beneficial long-term effects.

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Open Access

Peer-reviewed

Research Article

The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Health Sciences, University of York, York, England, United Kingdom

Roles Investigation, Methodology, Supervision, Writing – review & editing

Affiliations Centre of Health Economics, University of York, York, England, United Kingdom, Luxembourg Institute of Socio-economic Research (LISER), Luxembourg

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliations Department of Health Sciences, University of York, York, England, United Kingdom, Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada

Roles Conceptualization, Investigation, Supervision, Writing – review & editing

• Darius Erlangga, 
• Marc Suhrcke, 
• Shehzad Ali, 
• Karen Bloor

• Published: August 28, 2019
• https://doi.org/10.1371/journal.pone.0219731
• Reader Comments

7 Nov 2019: Erlangga D, Suhrcke M, Ali S, Bloor K (2019) Correction: The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review. PLOS ONE 14(11): e0225237. https://doi.org/10.1371/journal.pone.0225237 View correction

Expanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years.

We reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status.

8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies).

Interpretation

Increased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage.

Citation: Erlangga D, Suhrcke M, Ali S, Bloor K (2019) The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review. PLoS ONE 14(8): e0219731. https://doi.org/10.1371/journal.pone.0219731

Editor: Sandra C. Buttigieg, University of Malta Faculty of Health Sciences, MALTA

Received: March 19, 2018; Accepted: July 2, 2019; Published: August 28, 2019

Copyright: © 2019 Erlangga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The search strategy for this review is available in Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In recent decades, achieving universal health coverage (UHC) has been a major health policy focus globally.[ 1 – 3 ] UHC entitles all people to access healthcare services through publicly organised risk pooling,[ 4 ] safeguarding against the risk of catastrophic healthcare expenditures.[ 5 ] Low- and middle-income countries (LMICs) face particular challenges in achieving UHC due to particularly limited public resources for health care, inefficient allocation, over-reliance on out-of-pocket payments, and often large population size.[ 5 ] As a result, access to health care and the burden of financial cost in LMICs tends to be worse for the poor, often resulting in forgone care.[ 6 – 8 ]

Introducing and increasing the coverage of publicly organised and financed health insurance is widely seen as the most promising way of achieving UHC,[ 9 , 10 ] since private insurance is mostly unaffordable for the poor.[ 11 ] Historically, social health insurance, tax-based insurance, or a mix of the two have been the dominant health insurance models amongst high income countries and some LMICs, including Brazil, Colombia, Costa Rica, Mexico, and Thailand.[ 12 ] This is partly influenced by the size of the formal sector economy from which taxes and payroll contributions can be collected. In recent decades, community-based health insurance (CBHI) or “mutual health organizations” have become increasingly popular among LMICs, particularly in Sub-Saharan Africa (e.g. Burkina Faso,[ 13 ] Senegal[ 14 ] and Rwanda[ 15 ]) as well as Asia (e.g. China[ 16 ] and India[ 17 ]). CBHI has emerged as an alternative health financing strategy, particularly in cases where the public sector has failed to provide adequate access to health care.[ 18 ]

We searched for existing systematic reviews on health insurance in the Cochrane Database for Systematic Reviews, Medline, Embase, and Econlit. Search terms “health insurance”, “low-middle income countries”, and “utilisation” were used alongside methodological search strategy to locate reviews. Seven systematic reviews were identified of varying levels of quality, [ 19 – 26 ] with Acharya et al.[ 27 ] being the most comprehensive. The majority of existing reviews has suggested that publicly-funded health insurance has typically shown a positive impact on access to care, while the picture for financial protection was mixed, and evidence of the impact on health status was very sparse.

This study reviews systematically the recent fast-growing evidence on the impact of health insurance on health care utilisation, financial protection and health status in LMICs. Since the publication of Acharya et al. (which conducted literature searches in July 2010), the empirical evidence on the impact of health insurance has expanded significantly in terms of quantity and quality, with growing use of sophisticated techniques to account for statistical challenges[ 28 ] (particularly insurance selection bias). This study makes an important contribution towards our understanding of the impact of health insurance in LMICs, taking particular care in appraising the quality of studies. We recognise the heterogeneity of insurance schemes implemented in LMICs and therefore do not attempt to generalise findings, but we aim to explore the pattern emerging from various studies and to extract common factors that may affect the effectiveness of health insurance, that should be the focus of future policy and research. Furthermore, we explore evidence of moral hazard in insurance membership, an aspect that was not addressed in the Acharya et al review.[ 27 ]

This review was planned, conducted, and reported in adherence with PRISMA standards of quality for reporting systematic reviews.[ 29 ]

Participants

Studies focusing on LMICs are included, as measured by per capita gross national income (GNI) estimated using the World Bank Atlas method per July 2016.[ 30 ]

Intervention

Classification of health insurance can be complicated due to the many characteristics defining its structure, including the mode of participation (compulsory or voluntary), benefit entitlement, level of membership (individual or household), methods for raising funds (taxes, flat premium, or income-based premium) and the mechanism and extent of risk pooling [ 31 ]. For the purpose of this review, we included all health insurance schemes organised by government, comprising social health insurance and tax-based health insurance. Private health insurance was excluded from our review, but we recognise the presence of community-based health insurance (CBHI) in many LMICs, especially in Africa and Asia [ 18 ]. We also therefore included CBHI if it was scaled up nationally or was actively promoted by national government. Primary studies that included both public and private health insurance were also considered for inclusion if a clear distinction between the two was made in the primary paper. Studies examining other types of financial incentives to increase the demand for healthcare services, such as voucher schemes or cash transfers, were excluded.

Control group

In order to provide robust evidence on the effect on insurance, it is necessary to compare an insured group with an appropriate control group. In this review, we selected studies that used an uninsured population as the control group. Multiple comparison groups were allowed, but an uninsured group had to be one of them.

Outcome measures

We focus on three main outcomes:

• Utilisation of health care facilities or services (e.g. immunisation coverage, number of visits, rates of hospitalisation).
• Financial protection, as measured by changes in out-of-pocket (OOP) health expenditure at household or individual level, and also catastrophic health expenditure or impoverishment from medical expenses.
• Health status, as measured by morbidity and mortality rates, indicators of risk factors (e.g. nutritional status), and self-reported health status.

The scope of this review is not restricted to any level of healthcare delivery (i.e. primary or secondary care). All types of health services were considered in this review.

Types of studies

The review includes randomized controlled trials, quasi-experimental studies (or “natural experiments”[ 32 ]), and observational studies that account for selection bias due to insurance endogeneity (i.e. bias caused by insurance decisions that are correlated with the expected level of utilisation and/or OOP expenditure). Observational studies that did not take account of selection bias were excluded.

Databases and search terms

A search for relevant articles was conducted on 6 September 2016 using peer-reviewed databases (Medline, Embase, Econlit, CINAHL Plus via EBSCO and Web of Science) and grey literatures (WHO, World Bank, and PAHO). Our search was restricted to studies published since July 2010, immediately after the period covered by the earlier Acharya et al. (2012) review. No language restrictions were applied. Full details of our search strategy are available in the supporting information ( S1 Table ).

Screening and data extraction

Two independent reviewers (DE and MS) screened all titles and abstracts of the initially identified studies to determine whether they satisfied the inclusion criteria. Any disagreement was resolved through mutual consensus. Full texts were retrieved for the studies that met the inclusion criteria. A data collection form was used to extract the relevant information from the included studies.

Assessment of study quality

We used the Grades of Assessment, Development and Evaluation (GRADE) system checklist[ 33 , 34 ] which is commonly used for quality assessment in systematic reviews. However, GRADE does not rate observational studies based on whether they controlled for selection bias. Therefore, we supplemented the GRADE score with the ‘Quality of Effectiveness Estimates from Non-randomised Studies’ (QuEENS) checklist.[ 35 ]

cRandomised studies were considered to have low risk of bias. Non-randomised studies that account for selection on observable variables, such as propensity score matching (PSM), were categorised as high risk of bias unless they provided adequate assumption checks or compared the results to those from other methods, in which case they may be classed as medium risk. Non-randomised studies that account for selection on both observables and unobservables, such as regression with difference-in-differences (DiD) or Heckman sample selection models, were considered to have medium risk of bias–some of these studies were graded as high or low risk depending on sufficiency of assumption checks and comparison with results from other methods.

Heterogeneity of health insurance programmes across countries and variability in empirical methods used across studies precluded a formal meta-analysis. We therefore conducted a narrative synthesis of the literature and did not report the effect size. Throughout this review, we only considered three possible effects: positive outcome, negative outcome, or no statistically significant effect (here defined as p-value > 0.1).

Results of the search

Our database search identified 8,755 studies. Five additional studies were retrieved from grey literature. After screening of titles and abstracts, 118 studies were identified as potentially relevant. After reviewing the full-texts, 68 studies were included in the systematic review (see Fig 1 for the PRISMA diagram). A full description of the included studies is presented in the supporting information ( S2 Table ). Of the 68 included studies, 40 studies examined the effect on utilisation, 46 studies on financial protection, and only 12 studies on health status (see Table 1 ).

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https://doi.org/10.1371/journal.pone.0219731.g001

https://doi.org/10.1371/journal.pone.0219731.t001

Utilisation of health care

Table 2 collates evidence on the effects of health insurance on utilisation of healthcare services. Three main findings were observed:

• Evidence on utilisation of curative care generally suggested a positive effect, with 30 out of 38 studies reporting a statistically significant positive effect.
• Evidence on preventive care is less clear with 4 out of 7 studies reporting a positive effect, two studies finding a negative effect and one study reporting no effect.
• Among the higher quality studies, i.e. those that suitably controlled for selection bias reflected by moderate or low GRADE score and low risk of bias (score = 3) on QuEENS, seven studies reported a positive relationship between insurance and utilisation. One study[ 36 ] reported no statistically significant effect, and another study found a statistically significant negative effect.[ 37 ]

https://doi.org/10.1371/journal.pone.0219731.t002

Financial protection

Overall, evidence on the impact of health insurance on financial protection is less clear than that for utilisation (see Table 3 ). 34 of the 46 studies reported the impact of health insurance on the level of out-of-pocket health expenditure. Among those 34 studies, 17 found a positive effect (i.e. a reduction in out-of-pocket expenditure), 15 studies found no statistically significant effect, and two studies–from Indonesia[ 59 ] and Peru[ 62 ]–reported a negative effect (i.e. an increase in out-of-pocket expenditure).

https://doi.org/10.1371/journal.pone.0219731.t003

Another financial protection measure is the probability of incurring catastrophic health expenditure defined as OOP exceeding a certain threshold percentage of total expenditure or income. Of the 14 studies reporting this measure, nine reported reduction in the risk of catastrophic expenditure, three found no statistically significant difference, and two found a negative effect of health insurance. Only four studies reported sensitivity analysis varying changes in the threshold level,[ 59 , 62 , 75 , 76 ] though this did not materially affect the findings.

• Two studies used a different measure of financial protection, the probability of impoverishment due to catastrophic health expenditure, reporting conflicting findings.[ 77 , 78 ] Finally, four studies evaluated the effect on financial protection by assessing the impact of insurance on non-healthcare consumption or saving behaviour, such as non-medical related consumption[ 79 ], probability of financing medical bills via asset sales or borrowing[ 40 ], and household saving[ 80 ]. No clear pattern can be observed from those four studies.

Health status

Improving health is one of the main objectives of health insurance, yet very few studies thus far have attempted to evaluate health outcomes. We identified 12 studies, with considerable variation in the precise health measure considered (see Table 4 ). There was some evidence of positive impact on health status: nine studies found a positive effect, one study reported a negative effect, and two studies reported no effect.

https://doi.org/10.1371/journal.pone.0219731.t004

Type of insurance and countries

Considering the heterogeneity of insurance schemes among different countries, we attempted to explore the aggregate results by the type of insurance scheme and by country. Table 5 provides a summary of results classified by three type of insurance scheme: community-based health insurance, voluntary health insurance (non-CBHI), and compulsory health insurance. This division is based on the mode of participation (compulsory vs voluntary), which may affect the presence of adverse selection and moral hazard. Premiums are typically community-rated in CBHI, risk-rated in voluntary schemes and income-rated in compulsory schemes.

https://doi.org/10.1371/journal.pone.0219731.t005

In principle, CBHI is also considered a voluntary scheme, but we separated it to explore whether the larger size of pooling from non-CBHI schemes may affect the outcomes. Social health insurance is theoretically a mandatory scheme that requires contribution from the enrolees. However, in the context of LMICs, the mandatory element is hard to enforce, and in practice the scheme adopts a voluntary enrolment. Additionally, the government may also want to subsidise the premium for poor people. Therefore, in this review SHI schemes can fall into either the voluntary health insurance (non-CBHI) or compulsory health insurance (non-CBHI), depending on the target population defined in the evaluation study. Lastly, we chose studies with high quality/low risk only to provide more robust results.

Based on the summary in Table 5 , the effect on utilisation overall does not differ based on type of insurance, with most evidence suggesting an overall increase in utilisation by the insured. The two studies showing no effect or reduced consumption of care were conducted in two different areas of India, which may–somewhat tentatively–suggest a common factor unique to India’s health system that may compromise the effectiveness of health insurance in increasing utilisation.

Regarding financial protection, the evidence for both CBHI and non-CBHI voluntary health insurance is inconclusive. Furthermore, there is an indication of heterogeneity by supply side factors captured by proximity to health facilities. Evidence from studies exploring subsidised schemes suggests no effect on financial protection, even a negative effect among the insured in Peru.

Lastly, evidence for health status may be influenced by how health outcomes are measured. Studies exploring specific health status, (examples included health indexes, wasting, C-reactive protein, and low birth weight), show a positive effect, whereas studies using mortality rates tends to show no effect or even negative effects. Studies exploring CBHI scheme did not find any evidence of positive effect on health status, as measured either by mortality rate or specific health status.

This review synthesises the recent, burgeoning empirical literature on the impact of health insurance in LMICs. We identified a total of 68 eligible studies over a period of six years–double the amount identified by the previous review by Acharya et al. over an approximately 60-year time horizon (1950—July 2010). We used two quality assessment checklists to scrutinise the study methodology, taking more explicit account of the methodological robustness of non-experimental designs.

Programme evaluation has been of interest to many researchers for reporting on the effectiveness of a public policy to policymakers. In theory, the gold standard for a programme evaluation is the randomised control trial, in which the treatment is randomly assigned to the participants. The treatment assignment process has to be exogenous to ensure that any observed effect between the treated and control groups can only be caused by the difference in the treatment assignment. Unfortunately, this ideal scenario is often not feasible in a public policy setting. Our findings showed that only three papers between 2010 and 2016 were able to conduct a randomised study to evaluate the impact of health insurance programmes in developing countries, particularly CBHI [ 38 , 75 , 103 ]. Policymakers may believe in the value of an intervention regardless of its actual evidence base, or they may believe that the intervention is beneficial and that no one in need should be denied it. In addition, policymakers are inclined to demonstrate the effectiveness of an intervention that they want implemented in the most promising contexts, as opposed to random allocation [ 104 ].

Consequently, programme evaluators often have to deal with a non-randomised treatment assignment which may result in selection bias problems. Selection bias is defined as a spurious relationship between the treatment and the outcome of interest due to the systematic differences between the treated and the control groups [ 105 ]. In the case of health insurance, an individual who chooses to enrol in the scheme may have different characteristics to an individual who chooses not to enrol. When those important characteristics are unobservable, the analyst needs to apply more advanced techniques and, sometimes, stronger assumptions. Based on our findings, we noted several popular methods, including propensity score matching (N = 8), difference-in-difference (N = 10), fixed or random effects of panel data (N = 6), instrumental variables (N = 12) and regression discontinuity (N = 6). Those methods have varying degree of success in controlling the unobserved selection bias and analysts should explore the robustness of their findings by comparing initial findings with other methods by testing important assumptions. We noted some papers combining two common methods, such as difference-in-difference with propensity score matching (N = 10) and fixed effects with instrumental variables (N = 8), in order to obtain more robust results.

Overall effect

Compared with the earlier review, our study has found stronger and more consistent evidence of positive effects of health insurance on health care utilisation, but less clear evidence on financial protection. Restricting the evidence base to the small subset of randomised studies, the effects on financial protection appear more consistently positive, i.e. three cluster randomised studies[ 39 , 75 , 76 ] showed a decline in OOP expenditure and one randomised study[ 36 ] found no significant effect.

Besides the impact on utilisation and financial protection, this review identified a number of good quality studies measuring the impact of health insurance on health outcomes. Twelve studies were identified (i.e. twice as many as those published before 2010), nine of which showed a beneficial health effect. This holds for the subset of papers with stronger methodology for tackling selection bias.[ 39 , 49 , 89 , 103 ] In cases where a health insurance programme does not have a positive effect on either utilisation, financial protection, and health status, it is particularly important to understand the underlying reasons.

Possible explanation of heterogeneity

Payment system..

Heterogeneity of the impact of health insurance may be explained by differences in health systems and/or health insurance programmes. Robyn et al. (2012) and Fink et al (2013) argued that the lack of significant effect of insurance in Burkina Faso may have been partially influenced by the capitation payment system. As the health workers relied heavily on user fees for their income, the change of payment system from fee-for-services to capitation may have discouraged provision of high quality services. If enrolees perceive the quality of contracted providers as bad, they might delay seeking treatment, which in turn could impact negatively on health.

Several studies from China found the utilisation of expensive treatment and higher-level health care facilities to have increased following the introduction of the insurance scheme.[ 41 , 44 , 45 , 88 ] A fee-for-service payment system may have incentivised providers to include more expensive treatments.[ 43 , 83 , 88 ] Recent systematic reviews suggested that payment systems might play a key role in determining the success of insurance schemes,[ 23 , 106 ] but this evidence is still weak, as most of the included studies were observational studies that did not control sufficiently for selection bias.

Uncovered essential items.

Sood et al. (2014) found no statistically significant effect of community-based health insurance on utilisation in India. They argued that this could be caused by their inability to specify the medical conditions covered by the insurance, causing dilution of a potential true effect. In other countries, transportation costs[ 69 ] and treatments that were not covered by the insurance[ 59 , 60 ] may explain the absence of a reduction in out-of-pocket health expenditures.

Methodological differences.

Two studies in Georgia evaluated the same programme but with different conclusions.[ 50 , 51 ] This discrepancy may be explained by the difference in the estimated treatment effect: one used average treatment effect (ATE), finding no effect, and another used average treatment effect on the treated (ATT), reporting a positive effect. ATE is of prime interest when policymakers are interested in scaling up the programme, whereas ATT is useful to measure the effect on people who were actually exposed to insurance.[ 107 ]

Duration of health insurance.

We also found that the longer an insurance programme has been in place prior to the timing of the evaluation, the higher the odds of improved health outcomes. It is plausible that health insurance would not change the health status of population instantly upon implementation.[ 21 ] While there may be an appetite among policymakers to obtain favourable short term assessments, it is important to compare the impact over time, where feasible.

Moral hazard.

Acharya et al (2012) raised an important question about the possibility of a moral hazard effect as an unintended consequence of introducing (or expanding) health insurance in LMICs. We found seven studies exploring ex-ante moral hazard by estimating the effect on preventive care. If uninsured individuals expect to be covered in the future, they may reduce the consumption of preventive care or invest less in healthy behaviours.[ 108 , 109 ] Current overall evidence cannot suggest a definite conclusion considering the heterogeneity in chosen outcomes. One study found that the use of a self-treated bed nets to prevent malaria declined among the insured group in Ghana[ 54 ] while two studies reported an increase in vaccination rates[ 62 ] and the number of prenatal care visits[ 55 , 62 ]among the insured group. Another study reported no evidence that health insurance encouraged unhealthy behaviour or reduction of preventive efforts in Thailand.[ 66 ]

Two studies from Colombia found that the insured group is more likely to increase their demand for preventive treatment.[ 47 , 49 ] As preventive treatment is free for all, both authors attributed this increased demand to the scheme’s capitation system, incentivising providers to promote preventive care to avoid future costly treatments.[ 110 ] Another study of a different health insurance programme in Colombia found an opposite effect.[ 48 ]

Study limitations.

This review includes a large variety of study designs and indicators for assessing the multiple potential impacts of health insurance, making it hard to directly compare and aggregate findings. For those studies that used a control group, the use of self-selected controls in many cases creates potential bias. Studies of the effect of CBHI are often better at establishing the counterfactual by allowing the use of randomisation in a small area, whereas government schemes or social health insurance covering larger populations have limited opportunity to use randomisation. Non-randomised studies are more susceptible to confounding factors unobserved by the analysts. For a better understanding of the links between health insurance and relevant outcomes, there is also a need to go beyond quantitative evidence alone and combine the quantitative findings with qualitative insights. This is particularly important when trying to interpret some of the counterintuitive results encountered in some studies.

The impact of different health insurance schemes in many countries on utilisation generally shows a positive effect. This is aligned with the supply-demand theory in whichhealth insurance decreases the price of health care services resulting in increased demand. It is difficult to draw an overall conclusion about the impact of health insurance on financial protection, most likely because of differences in health insurance programmes. The impact of health insurance on health status suggests a promising positive effect, but more studies from different countries is required.

The interest in achieving UHC via publicly funded health insurance is likely to increase even further in the coming years, and it is one of the United Nation’s Sustainable Development Goals (SDGs) for 2030[ 111 ]. As public health insurance is still being widely implemented in many LMICs, the findings from this review should be of interest to health experts and policy-makers at the national and the international level.

Supporting information

S1 table. search strategies..

https://doi.org/10.1371/journal.pone.0219731.s001

S2 Table. Study characteristic and reported effect from the included studies (N = 68).

https://doi.org/10.1371/journal.pone.0219731.s002

S3 Table. PRISMA 2009 checklist.

https://doi.org/10.1371/journal.pone.0219731.s003

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104 Health Insurance Essay Topic Ideas & Examples

Inside This Article

Health insurance is a vital aspect of maintaining one's overall well-being and financial security. As such, it is important to stay informed about the various aspects of health insurance, including coverage options, costs, and benefits. To help you better understand this complex topic, here are 104 health insurance essay topic ideas and examples that you can use for your research or writing assignments.

• The importance of health insurance in modern society
• Types of health insurance plans: HMO, PPO, EPO, POS
• How does health insurance work?
• The Affordable Care Act and its impact on health insurance coverage
• Health insurance for seniors: Medicare vs. Medicaid
• The role of health insurance in preventive care
• Health insurance coverage for mental health services
• The rising cost of health insurance premiums
• The benefits of employer-sponsored health insurance
• Health insurance for small businesses
• Health insurance coverage for pre-existing conditions
• The impact of COVID-19 on health insurance coverage
• Health insurance options for freelancers and gig workers
• Health savings accounts (HSAs) and their role in health insurance
• The ethics of denying coverage for certain medical treatments
• The role of health insurance in reducing healthcare disparities
• Health insurance coverage for alternative medicine and holistic treatments
• The impact of lifestyle choices on health insurance premiums
• The role of health insurance in promoting healthcare access for all
• The pros and cons of private vs. public health insurance
• Health insurance coverage for maternity care and childbirth
• The rising cost of prescription drugs and its impact on health insurance
• The role of health insurance in managing chronic conditions
• Health insurance coverage for dental care and vision services
• The impact of changing job markets on health insurance coverage
• The role of health insurance in promoting healthy behaviors
• Health insurance coverage for transgender individuals
• The impact of mental health parity laws on health insurance coverage
• The role of health insurance exchanges in expanding coverage options
• Health insurance coverage for long-term care services
• The impact of medical bankruptcies on health insurance coverage
• The role of health insurance in promoting healthcare innovation
• Health insurance coverage for telemedicine services
• The impact of insurance mergers on health insurance coverage
• The role of health insurance in promoting patient-centered care
• Health insurance coverage for genetic testing and personalized medicine
• The impact of high-deductible health plans on health insurance coverage
• The role of health insurance in promoting health equity
• Health insurance coverage for addiction treatment services
• The impact of insurance fraud on health insurance coverage
• The role of health insurance in promoting healthcare transparency
• Health insurance coverage for preventive screenings and vaccinations
• The impact of healthcare reform on health insurance coverage
• The role of health insurance in promoting patient safety
• Health insurance coverage for emergency medical services
• The impact of technology on health insurance coverage
• The role of health insurance in promoting patient empowerment
• Health insurance coverage for home health care services
• The impact of malpractice lawsuits on health insurance coverage
• The role of health insurance in promoting healthcare quality
• Health insurance coverage for international travel
• The impact of medical tourism on health insurance coverage
• The role of health insurance in promoting healthcare affordability
• Health insurance coverage for complementary and integrative medicine
• The impact of data breaches on health insurance coverage
• The role of health insurance in promoting healthcare efficiency
• Health insurance coverage for mental health first aid training
• The impact of natural disasters on health insurance coverage
• The role of health insurance in promoting healthcare sustainability
• Health insurance coverage for telepsychiatry services
• The impact of environmental factors on health insurance coverage
• The role of health insurance in promoting healthcare resilience
• Health insurance coverage for palliative care services
• The impact of social determinants of health on health insurance coverage
• The role of health insurance in promoting healthcare accountability
• Health insurance coverage for genetic counseling services
• The impact of political factors on health insurance coverage
• The role of health insurance in promoting healthcare governance
• Health insurance coverage for mindfulness-based interventions
• The impact of economic factors on health insurance coverage
• The role of health insurance in promoting healthcare leadership
• Health insurance coverage for integrative health coaching services
• The impact of social media on health insurance coverage
• The role of health insurance in promoting healthcare advocacy
• Health insurance coverage for art therapy services
• The impact of artificial intelligence on health insurance coverage
• The role of health insurance in promoting healthcare activism
• Health insurance coverage for music therapy

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Health Insurance Reform Has Surprisingly Little Impact on Actual Health

T he typical American’s health compares poorly to that of their counterparts in other high-income countries, even though the U.S. spends twice as much as these countries do on medical care. Behind that middling average lies substantial health inequality. A 40-year-old American male can expect to live 15 years less if he’s one of the poorest 1% of Americans rather than one of the richest 1%. Black children who live in the richest parts of the United States have higher mortality rates than White children in the poorest parts of the country.

Many have put these observations together with another aspect of U.S. “exceptionalism”: We are the only high-income country without universal health insurance coverage. And they have concluded that the key to improving health and reducing health inequality in the U.S. is to finally enact universal coverage.

They’re wrong. While these two facts are correct, they have very little to do with each other. There are good reasons to support universal health coverage, but noticeably improving population health is not one of them.

Indeed, the evidence suggests that the health disparities among Americans are not driven by differences in access to health insurance or to medical care. Rather, the key to improving health is far more complex: It lies in changing health behaviors and reducing exposure to external sources of poor health.

Perhaps the clearest evidence for how little impact health insurance reform has on health comes from the experience of other countries which have universal health insurance but also experience substantial health inequality. Consider Sweden and Norway , two Nordic countries with universal health insurance as well as a cradle-to-grave generous social safety net. Yet differences in life expectancy between adults in the top 10% and bottom 10% of the national income distribution in those countries are similar to the disparities in the United States.

Read More: Long Waits, Short Appointments, Huge Bills: U.S. Health Care Is Causing Patient Burnout

Or consider the enormous differences across the country in remaining life expectancy for elderly Americans, all of whom are covered by the same Medicare health insurance program. Researchers have identified which cities in the U.S. are better or worse for elderly longevity , and also which tend to provide more medical care than others . But, the evidence indicates, the places you’d want to move to in order to increase your life expectancy in retirement aren’t the same as the places to move to if you want to receive more medical care.

Indeed, there is widespread agreement among researchers that medical care, let alone health insurance, is not the only—or even the most important—determinant of health. Rather, the key to better health and smaller health disparities lies in the air we breathe, the food we eat, and the cigarettes we do or do not smoke. Which means that the key public policies for improving health must be those that tackle these sources of poor health through pollution regulation, or soda and cigarette taxes. The path to major health improvements doesn’t run through health insurance and health care policy.

How can this possibly be?

It is not because health insurance is not important for health. Of course it is .  But its effects are too small for health insurance reform to make much of a dent in the large U.S. income-health gradient, or to substantially improve the poor health of average Americans.

Behind this relative unimportance of health insurance coverage for health is a startling, but little-understood reality: No one in America is actually uninsured when it comes to their health care. Rather, the nominally “uninsured”—those who lack formal health insurance coverage—nonetheless receive a substantial amount of medical care which they don’t pay for.  

There is a vast web of public policy requirements and dedicated public funding to provide the nominally uninsured with free or heavily discounted medical care. And no, we’re not just talking about the emergency room. Through a piecemeal slew of policies at the federal, state, and local level, the government has created a large, complex web of publicly-regulated, publicly-funded programs that provide free or low-fee preventive care, care management for chronic health problems, and non-emergency hospital care for the uninsured and under-insured.

This point was made clear by data from Oregon, where the state ran a lottery for health insurance coverage in 2008. The process was similar to a clinical trial for a new drug, in which some patients are randomly assigned the new drug and others are assigned an older drug or a sugar pill. Except in this case, Oregon randomly assigned public health insurance coverage to about 10,000 low-income, uninsured adults but not to the thousands of others who had signed up to “win” free public health insurance. The results of this lottery made clear that providing formal health insurance coverage to the uninsured provides them with real benefits: better protection against expensive medical bills, greater likelihood of having a medical home, more access to medical care, and ultimately, improved health.

But the experiment’s results also revealed something striking about the experience of the uninsured: The uninsured receive about four-fifths of the medical care that they would get had they been insured. This medical care includes primary care, preventive care, prescription drugs, emergency room visits, and hospital admissions. And they pay for only about 20 cents out of every dollar of medical care that they receive. In other words, they are not actually uninsured. Rather, there’s a lot more commonality in the medical care received and (not) paid for by the insured and the uninsured than those labels might suggest.

And once we realize that everyone in America can access medical care, it becomes much clearer why formalizing this access – while important for other reasons – is unlikely to make an important difference for people’s health, or substantially reduce the large disparities in population health.

The surprisingly limited role for health care policy or health insurance in driving population health is not a new observation. A half century ago, the economist Victor Fuchs – who at age 99 is now widely considered to be the founding father of the economic study of health – made this point in his now-famous “ Tale of Two States. ” He described two neighboring states in the Western U.S. that were similar along many of the dimensions believed to be important for health – including medical care, income, schooling, climate, and urbanicity. Yet in one state, the people were among the U.S. healthiest. Their neighbors in the other state were among the least healthy, with annual death rates that were 40% to 50% higher.

You may get an inkling of where Fuchs was going with this comparison when we tell you that the two states were Utah and Nevada. And that the residents of Utah were the ones enjoying much better health.

Fuchs famously attributed the lower-mortality rates of the clean-living, predominantly Mormon residents of Utah to their better health behaviors. Their Nevada neighbors enjoyed what he referred to as “more permissive” norms. Rates of smoking and drinking were much lower in Utah than in Nevada. And differences in mortality between the two states were particularly pronounced for diseases for which there was a direct link to such behaviors, such as lung cancer and cirrhosis of the liver.

Fuchs’s simple tabulations of publicly reported death rates by age and gender for Utah and Nevada appear antiquated by modern data science standards. But his central argument has stood the test of time. A subsequent half-century of confirmatory work has hammered home an important but often overlooked point: when it comes to improving health outcomes and reducing health disparities, health insurance policy is not the lever to lean on.

Adapted from We’ve Got You Covered: Rebooting American Health Care by Liran Einav and Amy Finkelstein, in agreement with Portfolio, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC. Copyright © Liran Einav and Amy Finkelstein, 2023.

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Why Do I Need Health Insurance?

I n the wild rollercoaster that is life today, it's vital to make sure you've got solid health insurance coverage backing you up. Securing a good health insurance plan is like your safety net, keeping you fit and protecting your pocket from surprise medical costs. Grasping the benefits of health insurance allows us to put our health first, ensuring we're ready for any surprise medical emergencies or healthcare requirements. Here, we delve into the importance of having health insurance and emphasizing the need for access to essential medical services.

Financial Protection: Easing the Financial Strain of Health Care Costs

Health insurance is a financial safety net that cushions the hefty expenses tied to healthcare and doctor's visits. Parent Your Parents explains Medicare plans may pay up to 80% of the costs of all of the doctor's visits and diagnostic tests that come before a cancer diagnosis until the health insurance deductible is met. This highlights that having health insurance can significantly reduce the out-of-pocket expenses and financial strain that may arise from unexpected medical procedures or treatments. Adequate health insurance coverage protects from the potentially exorbitant costs of healthcare services and treatments. Having health insurance provides financial security if you get sick or hurt.

Access to Quality Healthcare: Ensuring Timely and Essential Medical Services

Having health insurance provides individuals with access to essential healthcare services and timely medical treatments and interventions when needed. The CDC shares that 25.5% of individuals under 65 rely on public health insurance . Having solid health insurance lets you get top-notch medical care, see specialists when you need to, and undergo key treatments without a hitch. But getting preventive care keeps you healthier. By taking advantage of what health insurance offers, people can put their health and wellness first. Because health insurance covers preventive care and medications, people can focus on staying healthy instead of worrying about costs. Taking steps to prevent health issues and having your meds covered is all about keeping you healthy before anything goes south.

Boosting Active Engagement in Your Own Health Care

Getting a robust health insurance plan isn't just about easy access to needed drugs. It's also the nudge we need to take better care of ourselves and not skimp on preventive healthcare. With more than one-fifth of nursing home residents relying on antipsychotic medications , the National Institutes of Health shares that having comprehensive health insurance coverage can facilitate access to essential medications and preventive care services.

When you weave preventive care and medication benefits into your health plan, it's like saying ‘yes' to taking charge of your wellness. Having health insurance that covers preventive care and medications allows people to focus on staying healthy instead of just treating illnesses after they happen. Medical emergencies need quick, reliable help. It's a lifeline when facing serious health situations, ready to tackle existing conditions while focusing on proactive personal health management.

Giving Crucial Assistance When Health Emergencies Strike

When you're hit with a medical crisis, the real value of health insurance shines through. Health insurance helps pay for urgent medical care; it can be a lifesaver when accidents or emergencies happen. When health crises come knocking, a robust insurance plan is your ticket to swift and efficient medical aid. They can receive immediate attention and treatment during critical health situations. When you're slammed with hefty health scares, your health insurance steps up as a critical shield, footing the bill for hospital visits, urgent surgeries, or specialized treatments. They won't be left unprotected during unforeseen medical emergencies.

In plain terms, health insurance is crucial; think of it as your safety net for unexpected medical bumps in the road. Health insurance is like your financial bodyguard, stepping in to cover medical bills and giving you access to quality healthcare when life throws a curveball. Securing a robust health insurance plan is key to dodging the financial punch that sudden medical costs can throw at you.

The post Why Do I Need Health Insurance? appeared first on Kellys Thoughts On Things .

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Dr. Howard Markel Dr. Howard Markel

• Copy URL https://www.pbs.org/newshour/health/november-19-1945-harry-truman-calls-national-health-insurance-program

69 years ago, a president pitches his idea for national health care

This past July 30, we celebrated the 49th anniversary of Medicare and Medicaid . Readers of this column will recall it was on that date in 1965 when President Lyndon Baines Johnson formally signed these two programs into law in Independence, Missouri, as former president Harry S. Truman and his steadfast wife, Bess, looked on with pride. As LBJ handed “Give ‘Em Hell Harry” and Bess the pens he used to affix his signature to the document, the President proclaimed Mr. Truman as “the real daddy of Medicare.”

President Harry S. Truman proposed a universal health care program in 1945. Photo by Edmonston Studio — The Library of Congress

Today marks the reason why LBJ bestowed such presidential credit to Harry Truman.

Back in 1945 — a mere seven months into a presidency he inherited from Franklin D. Roosevelt — Truman proposed a “universal” national health insurance program. In his remarks to Congress, he declared, “Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”

69 years ago, President Truman outlined five critical goals of national health .

The first was to address the number and disparity of physicians, nurses and other health professionals, especially in low-income and rural communities where there were “no adequate facilities for the practice of medicine” and “the earning capacity of the people in some communities makes it difficult if not impossible for doctors who practice there to make a living.” To begin to correct this problem, Truman wanted the federal government to construct modern, quality hospital across the nation—especially where they did not yet exist.

The second issue was the need to develop and bolster public health services (both to control the spread of infectious diseases and improve sanitary conditions across the nation) and maternal and child health care. With respect to the latter, Harry Truman reminded Congress, “the health of American children, like their education, should be recognized as a definite public responsibility.”

Third, he sought to increase the nation’s investment in both medical research and medical education.

The fourth problem addressed the high cost of individual medical care. “The principal reason why people do not receive the care they need,” Truman noted, “is that they cannot afford to pay for it on an individual basis at the time they need it. This is true not only for needy persons. It is also true for a large proportion of normally self-supporting persons.”

And fifth, he focused on the lost earnings that inevitably occur when serious illness strikes. “Sickness,” Truman cogently explained, “not only brings doctor bills; it also cuts off income.

Not surprisingly, it was President Truman’s proposal to fix the 4th and 5th problems with a national health insurance plan that provoked the loudest opposition. Truman proposed that every wage earning American pay monthly fees or taxes to cover the cost of all medical expenses in time of illness. The plan also called for a cash balance to be paid to policyholders, in the event of injury or illness, to replace the income those individuals lost.

His measured and careful description of the plan merits quoting:

“Under the plan I suggest, our people would continue to get medical and hospital services just as they do now — on the basis of their own voluntary decisions and choices. Our doctors and hospitals would continue to deal with disease with the same professional freedom as now. There would, however, be this all-important difference: whether or not patients get the services they need would not depend on how much they can afford to pay at the time…None of this is really new. The American people are the most insurance-minded people in the world. They will not be frightened off from health insurance because some people have misnamed it ‘socialized medicine.’ I repeat — what I am recommending is not socialized medicine. Socialized medicine means that all doctors work as employees of government. The American people want no such system. No such system is here proposed.”

The Truman plan was quickly converted into a Social Security expansion bill sponsored by Sens. Robert Wagner (D-NY) and James Murray (D-MT) and Rep. John Dingell Sr. (D-MI). A version of this bill had been proposed in 1943, when FDR was still president, but died in committee both because of the pressures of the war and the lack of presidential pressure on Congress.

At first, things looked somewhat rosy for the reinvigorated 1945 bill: the Democrats still controlled both the House of Representatives and the Senate and a number of prominent Americans vociferously supported it. Still, the nation was weary from war, the high taxes necessary to pay for FDR’s New Deal, and what many Americans perceived to be a too intrusive federal government.

Almost as soon as the reinvigorated bill was announced, the once-powerful American Medical Association (AMA) capitalized on the nation’s paranoia over the threat of Communism and, despite Truman’s assertions to the contrary, attacked the bill as “socialized medicine.” Even more outrageous, the AMA derided the Truman administration as “followers of the Moscow party line.” During congressional hearings in 1946, the AMA proposed its own plan emphasizing private insurance options, which actually represented a political shift from its previous position opposing any third party members in the delivery of health care.

Another historical actor entering the fray was Senator Robert Taft (R-OH), who introduced the Taft-Smith-Ball bill, which called for matching grants to states to subsidize private health insurance for the needy. Although the AMA supported this bill, Truman was against it because he believed it would halt the political progress he had made in guaranteeing every American health insurance.

Hearings and politics continued through 1946 but little progress was made. During the midterm elections of 1946, the Republicans regained control of both the Senate and the House for the first time since 1929, making the bill a dead issue.

Harry Truman continued to make health insurance a major issue of his campaign platform in 1948 and specifically castigated the AMA for calling his plan “un-American”:

“I put it to you, it is un-American to visit the sick, aid the afflicted or comfort the dying? I thought that was simple Christianity.”

Truman famously fooled the pollsters by winning re-election in 1948 and even the Congress was restored to Democratic control that fall. But this political power was no match for the AMA’s redoubled lobbying and advertising efforts, which were endorsed by more than 1,800 national organizations, including the American Bar Association, the American Legion and the American Farm Bureau Federation. Public support waned — and the bill quietly died (again) — as the middle class purchased private health insurance plans, labor unions began collectively bargaining for their members’ health benefits, and the advent of the Korean War.

Truman later called the failure to pass a national health insurance program one of the most bitter and troubling disappointments in his presidency. He must have been overjoyed in 1965 to watch Lyndon Johnson enact a health insurance plan for the elderly and the needy. Nevertheless, the nation would have to wait another 45 years before the passage of the Patient Protection and Affordable Care Act of 2010, a law that remains in jeopardy after Nov. 7, when the U.S. Supreme Court took on still another legal challenge to its constitutionality . That said, many would insist there remains a great more work to do to make health care affordable and accessible for all Americans.

Dr. Howard Markel writes a monthly column for the PBS NewsHour, highlighting momentous historical events that continue to shape modern medicine. He is the director of the Center for the History of Medicine and the George E. Wantz Distinguished Professor of the History of Medicine at the University of Michigan and the author of “The Secret of Life:  Rosalind Franklin, James Watson, Francis Crick and the Discovery of DNA’s Double Helix” (W.W. Norton, September ’21).

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Vitamins and Minerals

Vitamins and minerals are micronutrients required by the body to carry out a range of normal functions. However, these micronutrients are not produced in our bodies and must be derived from the food we eat.

Vitamins are organic substances that are generally classified as either fat soluble or water soluble. Fat-soluble vitamins ( vitamin A , vitamin D , vitamin E , and vitamin K ) dissolve in fat and tend to accumulate in the body. Water-soluble vitamins ( vitamin C and the B-complex vitamins , such as vitamin B6 , vitamin B12 , and folate ) must dissolve in water before they can be absorbed by the body, and therefore cannot be stored. Any water-soluble vitamins unused by the body is primarily lost through urine.

Minerals are inorganic elements present in soil and water, which are absorbed by plants or consumed by animals. While you’re likely familiar with calcium , sodium , and potassium , there is a range of other minerals, including trace minerals (e.g. copper , iodine , and zinc ) needed in very small amounts.

In the U.S., the National Academy of Medicine (formerly the Institute of Medicine) develops nutrient reference values called the Dietary Reference Intakes (DRIs) for vitamins and minerals. [1] These are intended as a guide for good nutrition and as a scientific basis for the development of food guidelines in both the U.S. and Canada. The DRIs are specific to age, gender, and life stages, and cover more than 40 nutrient substances. The guidelines are based on available reports of deficiency and toxicity of each nutrient. Learn more about vitamins and minerals and their recommended intakes in the table below.

What about multivitamins?

A diet that includes plenty of fruits, vegetables , whole grains , good protein packages , and healthful fats should provide most of the nutrients needed for good health. But not everyone manages to eat a healthful diet. Multivitamins can play an important role when nutritional requirements are not met through diet alone. Learn more about vitamin supplementation .

Did you know? 

Vitamins and their precise requirements have been controversial since their discovery in the late 1800s and early 1900s. It was the combined efforts of epidemiologists, physicians, chemists, and physiologists that led to our modern day understanding of vitamins and minerals. After years of observation, experiments, and trial and error, they were able to distinguish that some diseases were not caused by infections or toxins—a common belief at the time—but by vitamin deficiencies. [2] Chemists worked to identify a vitamin’s chemical structure so it could be replicated. Soon after, researchers determined specific amounts of vitamins needed to avoid diseases of deficiency.

In 1912, biochemist Casimir Funk was the first to coin the term “vitamin” in a research publication that was accepted by the medical community, derived from “vita” meaning life, and “amine” referring to a nitrogenous substance essential for life. [3] Funk is considered the father of vitamin therapy, as he identified nutritional components that were missing in diseases of deficiency like scurvy (too little vitamin C ), beri-beri (too little vitamin B1 ), pellagra (too little vitamin B3 ), and rickets (too little vitamin D ). The discovery of all vitamins occurred by 1948.

Vitamins were obtained only from food until the 1930s when commercially made supplements of certain vitamins became available. The U.S government also began fortifying foods with specific nutrients to prevent deficiencies common at the time, such as adding iodine to salt to prevent goiter, and adding folic acid to grain products to reduce birth defects during pregnancy. In the 1950s, most vitamins and multivitamins were available for sale to the general public to prevent deficiencies, some receiving a good amount of marketing in popular magazines such as promoting cod liver oil containing vitamin D as bottled sunshine.

• Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); and Dietary Reference Intakes for Calcium and Vitamin D (2011) . These reports may be accessed via www.nap.edu .
• Semba RD. The discovery of the vitamins. Int J Vitam Nutr Res . 2012 Oct 1;82(5):310-5.
• Piro A, Tagarelli G, Lagonia P, Tagarelli A, Quattrone A. Casimir Funk: his discovery of the vitamins and their deficiency disorders. Ann Nutr Metab . 2010;57(2):85-8.

Last reviewed March 2023

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The Reasons for the Importance of a Healthy Lifestyle Research Paper

Research objectives, methodology.

Making the right diet directly affects the creation and maintenance of a healthy lifestyle. In addition, this directly relates to the sphere of consumption, since for proper nutrition you need to be attentive to the food you buy and select it taking into account specific parameters. The human body receives most of the substances necessary for its life, with food. So, be careful what you eat to stay healthy.

Find out what patterns of behavior contribute to the formation of healthy eating habits. To analyze the importance and benefits of switching to a healthy lifestyle through the formation of a suitable diet. To identify factors that contribute to the formation of a healthier attitude towards food in people.

The key audience will be young people from 16 to 25 years old.

Uncovering the reasons for the importance of a healthy lifestyle is important for the UK population. In this regard, it is important to determine the degree of influence of proper nutrition on human health. A proper diet is the key to starting to improve a person’s health and overall well-being. The topic is important because most people can form bad eating habits during their lives.

The main aspect that you need to adhere to in proper nutrition is the balance of various elements useful for the body. If you make the right diet where all the trace elements are combined in a suitable way, then a person may not limit himself to meals. It is extremely important for the body to receive a large amount of nutrients in order for all its functions to work properly. Food as such cannot be classified as harmful, its effect on a person depends on the quantity and frequency of meals. However, despite this, it is important when drawing up a diet to pay attention to the calorie content of food in order to control it.

In order for the diet to be balanced and varied, you need to eat in accordance with the recommended food pyramid above. There is a lot of conflicting information about healthy eating in the media. However, many information traps can further confuse a person who is about to start leading a healthy lifestyle. An important basis for the proper functioning of the whole organism is the receipt of a sufficient amount of combined nutrients. An unbalanced diet and the consumption of a large number of the same type of food can eventually lead to the failure of some functions. Such a diet does not contribute to health, but rather can significantly worsen it in a short time, so variety is important when choosing a diet. Otherwise, a person may develop various diseases such as obesity or kidney dysfunction. In addition, when developing a nutrition system, it is important to take into account many factors such as gender, age, illness and weight. Energy in the body is used for basic activities such as breathing, digestion, thinking, and heart function, but it is also needed for movement.

For example, adolescents have greater energy needs than older people; during pregnancy and breastfeeding, the need for nutrients increases; manual laborers need more energy than office workers. Portion balance and nutrient diversity an important aspects for whether a person has enough food to produce energy. All substances that people can use have different effects. This causes the body to need to combine them, thus compiling a nutrition scheme that would make it possible to fill all the necessary needs. Removing one element from the diet can also lead to negative consequences. Vitamins and minerals have different percentages in vegetables, fruits and berries, and therefore each variety should be considered separately. If you eat a variety of foods, you can get the right nutrients, and the body will be healthier and will work better.

The main threat to the body and the nutrition system is that a person gets used to eating as it is convenient for them. Monotony is due to many factors and can be the result of hard work and lack of time to cook. In some cases, a person himself limits himself from the use of certain food groups. In this case, it is important to ensure that the set of useful elements comes from authorized sources.

• Vegetarian and Non Vegetarian Healthier Diet
• Nutrition, Gastrointestinal Tract and Digestion
• The Importance of Study of Clinical Nutrition
• Gestational Diabetes in Pregnancy
• Prevention of Pressure Injuries
• Factors Influencing Patient Decision Making
• The Use of Web Resources in Medical Decision-Making
• Managing Obesity-Related Heart Failure
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2024, May 27). The Reasons for the Importance of a Healthy Lifestyle. https://ivypanda.com/essays/the-reasons-for-the-importance-of-a-healthy-lifestyle/

"The Reasons for the Importance of a Healthy Lifestyle." IvyPanda , 27 May 2024, ivypanda.com/essays/the-reasons-for-the-importance-of-a-healthy-lifestyle/.

IvyPanda . (2024) 'The Reasons for the Importance of a Healthy Lifestyle'. 27 May.

IvyPanda . 2024. "The Reasons for the Importance of a Healthy Lifestyle." May 27, 2024. https://ivypanda.com/essays/the-reasons-for-the-importance-of-a-healthy-lifestyle/.

1. IvyPanda . "The Reasons for the Importance of a Healthy Lifestyle." May 27, 2024. https://ivypanda.com/essays/the-reasons-for-the-importance-of-a-healthy-lifestyle/.

Bibliography

IvyPanda . "The Reasons for the Importance of a Healthy Lifestyle." May 27, 2024. https://ivypanda.com/essays/the-reasons-for-the-importance-of-a-healthy-lifestyle/.

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