Health insurance and mortality. Evidence from a national cohort

P. Franks, C. M. Clancy and M. R. Gold
Department of Family Medicine, University of Rochester, NY.

OBJECTIVE--To examine the relationship between lacking health insurance and the risk of subsequent mortality. DESIGN--Adults older than 25 years who reported they were uninsured or privately insured in the first National Health and Nutrition Examination Survey, a representative cohort of the US population, were followed prospectively from initial interview in 1971 through 1975 until 1987. PARTICIPANTS--Complete baseline and follow-up information was obtained on 4694 (91%) persons of the 5161 who reported not receiving publicly funded insurance at baseline. MAIN OUTCOME MEASURE--The relationship between insurance status and subsequent mortality was examined using Cox proportional hazards survival analysis. The analysis adjusted for gender, race, and baseline age, education, income, employment status, the presence of morbidity on examination, self-rated health, smoking status, leisure exercise, alcohol consumption, and obesity. The effects of interactions between insurance and all other baseline variables were also examined. RESULTS--By the end of the follow-up period, 9.6% of the insured and 18.4% of the uninsured had died. After adjustment for all other baseline variables, the hazard ratio for lacking insurance was 1.25 (95% confidence interval [CI], 1.00 to 1.55). The effect of insurance on mortality was comparable to that of education, income, and self-rated health. There were no statistically significant (P < .05) interactions. CONCLUSIONS--Lacking health insurance is associated with an increased risk of subsequent mortality, an effect that is evident in all sociodemographic health insurance and mortality groups examined.

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Disability Trends in Hong Kong Community-Dwelling Chinese Older Adults: 1996, 2000, and 2004
Chou and Leung
J Aging Health 2008;20:385-404.
ABSTRACT  

A 10-Year Experience with Universal Health Insurance in Taiwan: Measuring Changes in Health and Health Disparity
Wen et al.
ANN INTERN MED 2008;148:258-267.
ABSTRACT | FULL TEXT  

Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition
Hadley
JAMA 2007;297:1073-1084.
ABSTRACT | FULL TEXT  

Longitudinal Trends in Race/Ethnic Disparities in Leading Health Indicators From Adolescence to Young Adulthood
Harris et al.
Arch Pediatr Adolesc Med 2006;160:74-81.
ABSTRACT | FULL TEXT  

Projected health impact of the Los Angeles City living wage ordinance
Cole et al.
J. Epidemiol. Community Health 2005;59:645-650.
ABSTRACT | FULL TEXT  

Is It Ethical to Assign Medically Underserved African Americans to a Usual-Care Control Group in Community-Based Intervention Research?
Anderson
Diabetes Care 2005;28:1817-1820.
FULL TEXT  

Health Insurance Coverage And Mortality Among The Near-Elderly
McWilliams et al.
Health Aff (Millwood) 2004;23:223-233.
ABSTRACT | FULL TEXT  

Actual Causes of Death in the United States, 2000
Mokdad et al.
JAMA 2004;291:1238-1245.
ABSTRACT | FULL TEXT  

Undiagnosed Hypertension and Hypercholesterolemia Among Uninsured and Insured Adults in the Third National Health and Nutrition Examination Survey
Ayanian et al.
Am. J. Public Health 2003;93:2051-2054.
FULL TEXT  

Financing Graduate Medical Education: Sorting Out the Confusion
Covey and Friedlaender
JBJS 2003;85:1594-1604.
FULL TEXT  

Sicker and Poorer--The Consequences of Being Uninsured: A Review of the Research on the Relationship between Health Insurance, Medical Care Use, Health, Work, and Income
Hadley
Med Care Res Rev 2003;60:3S-75S.
ABSTRACT  

Commentary
Kronick
Med Care Res Rev 2003;60:100S-112S.
 

Socioeconomic Status and Dissatisfaction With Health Care Among Chronically Ill African Americans
Becker and Newsom
Am. J. Public Health 2003;93:742-748.
ABSTRACT | FULL TEXT  

Effects of Cost Sharing on Care Seeking and Health Status: Results From the Medical Outcomes Study
Wong et al.
Am. J. Public Health 2001;91:1889-1894.
ABSTRACT | FULL TEXT  

Lack of Health Insurance and Decline in Overall Health in Late Middle Age
Baker et al.
NEJM 2001;345:1106-1112.
ABSTRACT | FULL TEXT  

Improving The Quality Of Health Care: Who Will Lead?
Becher and Chassin
Health Aff (Millwood) 2001;20:164-179.
ABSTRACT | FULL TEXT  

Unmet Health Needs of Uninsured Adults in the United States
Ayanian et al.
JAMA 2000;284:2061-2069.
ABSTRACT | FULL TEXT  

Transforming Insurance Coverage Into Quality Health Care: Voltage Drops From Potential to Delivered Quality
Eisenberg and Power
JAMA 2000;284:2100-2107.
ABSTRACT | FULL TEXT  

Health Insurance and Access to Care for Symptomatic Conditions
Baker et al.
Arch Intern Med 2000;160:1269-1274.
ABSTRACT | FULL TEXT  

Supplemental Insurance and Mortality in Elderly Americans: Findings From a National Cohort
Doescher et al.
Arch Fam Med 2000;9:251-257.
ABSTRACT | FULL TEXT  

Physicians Helping the Underserved: The Reach Out Program
Scott et al.
JAMA 2000;283:99-104.
ABSTRACT | FULL TEXT  

Self-Rated Health and Mortality Over Three Decades: Results from a Time-Dependent Covariate Analysis
Strawbridge and Wallhagen
Research on Aging 1999;21:402-416.
ABSTRACT  

The Urgent Need to Improve Health Care Quality: Institute of Medicine National Roundtable on Health Care Quality
Chassin et al.
JAMA 1998;280:1000-1005.
ABSTRACT | FULL TEXT  

Ability to Obtain Medical Care for the Uninsured: How Much Does It Vary Across Communities?
Cunningham and Kemper
JAMA 1998;280:921-927.
ABSTRACT | FULL TEXT  

Monitoring the Consequences of Uninsurance: A Review of Methodologies
Brown et al.
Med Care Res Rev 1998;55:177-210.
ABSTRACT  

State-Specific Prevalence of Lapses in Health-Care-Insurance Coverage--United States, 1995
JAMA 1998;279:822-824.
FULL TEXT  

Denial of Health Insurance due to Preexisting Conditions: How Well does One High-Risk Pool Work?
Sumner et al.
Med Care Res Rev 1997;54:357-371.
ABSTRACT  

Chronic disability trends in elderly United States populations: 1982-1994
Manton et al.
Proc. Natl. Acad. Sci. USA 1997;94:2593-2598.
ABSTRACT | FULL TEXT  

The Medically Uninsured -- Will They Always Be with Us?
Schroeder
NEJM 1996;334:1130-1133.
FULL TEXT  

Survival after the Age of 80 in the United States, Sweden, France, England, and Japan
Manton and Vaupel
NEJM 1995;333:1232-1235.
ABSTRACT | FULL TEXT  

Categories of Adverse Health Effects from Indoor Air Pollution
Weetman and Munby
Indoor and Built Environment 1994;3:200-212.
ABSTRACT  

Coverage and Access in Health Care Reform
Reinhardt
NEJM 1994;330:1452-1453.
FULL TEXT