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John Z. Ayanian, MD, MPP; Joel S. Weissman, PhD; Eric C. Schneider, MD, MSc; Jack A. Ginsburg, MPE; Alan M. Zaslavsky, PhD

JAMA. 2000;284:2061-2069.

Context  In 1998, 33 million US adults aged 18 to 64 years lacked health insurance. Determining the unmet health needs of this population may aid efforts to improve access to care.

Objective  To compare nationally representative estimates of the unmet health needs of uninsured and insured adults, particularly among persons with major health risks.

Design and Setting  Random household telephone survey conducted in all 50 states and the District of Columbia through the Behavioral Risk Factor Surveillance System.

Participants  A total of 105,764 adults aged 18 to 64 years in 1997 and 117,364 in 1998, classified as long-term (1 year) uninsured (9.7%), short-term (<1 year) uninsured (4.3%), or insured (86.0%).

Main Outcome Measures  Adjusted proportions of participants who could not see a physician when needed due to cost in the past year, had not had a routine checkup within 2 years, and had not received clinically indicated preventive services, compared by insurance status.

Results  Long-term– and short-term–uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost (26.8%, 21.7%, and 8.2%, respectively), especially among those in poor health (69.1%, 51.9%, and 21.8%) or fair health (48.8%, 42.4%, and 15.7%) (P<.001). Long-term–uninsured adults in general were much more likely than short-term–uninsured and insured adults not to have had a routine checkup in the last 2 years (42.8%, 22.3%, and 17.8%, respectively) and among smokers, obese individuals, binge drinkers, and people with hypertension, elevated cholesterol, diabetes, or human immunodeficiency virus risk factors (P<.001). Deficits in cancer screening, cardiovascular risk reduction, and diabetes care were most pronounced among long-term–uninsured adults.

Conclusions  In our study, long-term–uninsured adults reported much greater unmet health needs than insured adults. Providing insurance to improve access to care for long-term–uninsured adults, particularly those with major health risks, could have substantial clinical benefits.

Author Affiliations: Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital (Drs Ayanian and Schneider), Department of Health Care Policy, Harvard Medical School (Drs Ayanian, Weissman, and Zaslavsky), Institute for Health Policy, Massachusetts General Hospital (Dr Weissman), and Department of Health Policy and Management, Harvard School of Public Health (Dr Schneider), Boston, Mass; and the American College of Physicians-American Society of Internal Medicine (Mr Ginsburg), Washington, DC.

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