By Dr Cary Presant MDIt would seem obvious that having health insurance helps to provide better access to doctors and provide better treatments for serious illnesses. However, since many patients without health insurance can access urgent care clinics, emergency rooms, attend health clinics, and obtain primary care for cash, it is important to look at the impact of health insurance on control of important illness, and the relative impact of health insurance on different races and ethnicity.
In a recent analysis, Dr. J. M. McWilliams and his co-workers from Harvard Medical School (Annals of Internal Medicine, Volume 150, Page 505-515, 2009) looked at the control of blood pressure, high cholesterol and diabetes in patients with and without medical insurance from 1999 to 2006. In their study, the authors evaluated the results of the National Health and Nutrition Examination Survey which was conducted yearly between 1999 and 2006. This survey, called NHANES, was a nationally representative study given to individuals through interviews, physical examination, and clinical testing. Between 1999 and 2006, over 41,000 people were evaluated, of which over 12,000 were between the ages of 40 and 85 years. The authors then looked at how often blood pressure was normalized to under 140/90 and how often the hemoglobin level was normal (the hemoglobin A1C under 7.0), and how often cholesterol was controlled to a normal level of under 200.
The quality of care of all of these people improved significantly over the seven years for all of the measures that they were evaluating. These trends showed an improvement regardless of race, with the exception that Latino patients showed little improvement in diabetes care. For example the control of hypertension improved from 46% to 56%. The control of diabetes improved from 38% to 59%. The cholesterol level improved from 43% control to 63% control. Importantly, improvements were seen in each of the races, and improvements were seen in all socioeconomic categories. However, at the end of the treatment period, racial differences which had existed before were still present, although they were less pronounced. Black and Hispanic patients still had inferior control rates for diabetes, blood pressure and cholesterol.
When the control rates were evaluated for patients who were under the age which made them eligible for Medicare compared to older ages, it was apparent that individuals over age 66 had reduced the differences between race, indicating that the increased ability of Black and Hispanic individuals to have health insurance (Medicare) resulted in a reduction in their degree of poor control of high blood pressure, diabetes, and cholesterol.
This finding of improvements in control over the most serious health risks in Americans by availability of universal health coverage for individuals in the Medicare ages suggests that as a nation we can improve health by providing universal healthcare to United States residents. Since 50 million individuals in the United States lack health insurance, finding some method to make health insurance available to those individuals is important in increasing the prevention of serious health conditions, and minimizing utilization of healthcare resources because of uncontrolled health risks. In that regard, the recent expansion of the State Children’s Health Insurance Program will contribute to improved long-term care. Since there is currently a debate on healthcare reform, examples of the benefits of health insurance such as the studies of these authors should result in improved decision making by our representatives who will try to improve the quality of care for all Americans.
But let’s look at the news from this study in other terms. The good news is that as a nation, the control of our most serious health problems (hypertension, diabetes, high blood pressure) has improved dramatically. So what is the bad news? The rate of control is still very poor for a country that spends as much on health care as we do. I am shocked that less than 2/3 of people have satisfactory control of these illnesses.
So here are the take home messages for you this week. Always have health insurance, because control of serious illnesses is less without it. And even with or without health insurance, be sure your illness is controlled well: know the target lab test values and see your health care provider often enough to adjust your treatments until you are a winner, and your numbers are good, less than the quality target level!
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