Triple Jeopardy: Low Income, Chronically Ill and Uninsured in America

At least 7.4 million working-age Americans living with chronic conditions such as diabetes, heart disease, and depression went without health insurance in 1999, according to research from the Center for Studying Health System Change (HSC). Uninsured people with chronic conditions reported worse health status and more functional limitations, and were three times more likely to go without needed medical care compared to their privately insured counterparts. The vast majority of those who delayed or missed care did so because of cost. About 63 percent of the uninsured with chronic conditions -- roughly 4.7 million Americans -- had family incomes below 200 percent of poverty (approximately $35,000 for a family of four in 2001). Facing the combined burdens of low income, ongoing health problems, and no insurance, this population confronted enormous barriers to obtaining and paying for necessary care.

Chronic Conditions Widespread Among Working-Age Adults

Although chronic illness is often thought of as primarily an elderly concern, it affected more than a third of working-age Americans. In 1999, 37 percent of nonelderly adults (18 to 64) -- approximately 60 million people -- reported seeing a physician in the past two years for at least one chronic condition, according to HSC's Community Tracking Study (CTS) Household Survey.

Working-age adults with chronic conditions were actually more likely to carry health insurance than those without -- 88 percent versus 81 percent in 1999. Among those with chronic conditions, 71 percent had private insurance, 12 percent were uninsured, 14 percent were covered by Medicare or Medicaid, and the rest had other coverage such as military insurance. Chronic conditions ranged widely in severity, from mild ailments causing few limitations to conditions that prevented people from performing basic daily activities. Consistent access to preventive and ongoing medical care could alleviate pain, boost productivity, and head off future complications and costs.

Worse Health Among Uninsured with Chronic Conditions

While the uninsured population overall tended to report better health than the insured, and fewer uninsured adults reported chronic conditions than privately insured adults (27 percent versus 35 percent), the picture changed dramatically when comparing uninsured and privately insured people who did have chronic conditions. Both groups reported an average of 1.6 conditions, but the uninsured with chronic conditions reported significantly worse health and more severe physical limitations.

Nearly 40 percent of uninsured people with chronic conditions described their health as fair or poor, compared with less than 20 percent of privately insured people with chronic conditions. The uninsured were also twice as likely to report physical limitations that seriously restricted moderate activities such as moving furniture or pushing a vacuum cleaner.

Uninsured Far Less Likely to Receive Needed Care

Uninsured people with chronic conditions faced particularly high risk of going without medical care. More than a quarter reported not obtaining needed care at least once in the past year, compared with less than 10 percent of those with private insurance. Over half of the uninsured with chronic conditions delayed care during the year, while only about a quarter of the privately insured did so. These disparities held even after adjusting for health status.

The negative effects of being uninsured were substantially greater for people with chronic conditions than for those without. The uninsured with chronic conditions were 3.3 times more likely to go without needed care than the privately insured -- compared with a 2.7 times differential for those without chronic conditions. The gap for delayed care was even wider, exceeding 35 percent.

Cost as the Dominant Barrier

Cost stood out as the principal barrier to care for the uninsured with chronic conditions, who tended to have considerably lower incomes. Sixty-three percent had family incomes under 200 percent of the federal poverty level, compared with just 18 percent of privately insured people with chronic conditions. Among the uninsured with chronic conditions who delayed or skipped care, the overwhelming majority cited cost as the reason. In contrast, fewer than half of the privately insured who delayed care pointed to cost.

Patterns in Health Care Utilization

Despite the difficulties they faced in obtaining timely care, most people with chronic conditions did receive some medical services. Still, the uninsured received significantly less care even after adjusting for health status. Nearly 25 percent of uninsured people with chronic conditions had not seen a doctor in the past year, compared with under 10 percent of the privately insured. The uninsured averaged four doctor visits, roughly 30 percent fewer than those with private coverage. While the two groups had similar hospital admission rates, the uninsured underwent about half as many surgeries, suggesting they received less intensive medical intervention.

Lack of insurance also appeared to drive inappropriate emergency department use. The uninsured with chronic conditions reported nearly twice the number of ER visits as the privately insured, leading to higher costs and potential capacity strain on hospital emergency services.

Policy Implications

People with chronic conditions were more likely to carry insurance, presumably because they valued and needed coverage more than the healthy population. Yet many could not obtain affordable coverage. The uninsured with chronic conditions faced more serious health problems and steeper barriers to needed care than their insured counterparts.

The long-term health consequences of missed preventive and ongoing care could be severe for this group. Indirect costs -- lost workdays and reduced productivity -- were substantial, and neglected care threatened to generate additional future productivity losses and economic costs. Providing nonurgent care in emergency departments was more expensive than delivering it in appropriate settings, and heavy ER use by the uninsured with chronic conditions could contribute to hospital capacity constraints and ambulance diversions. Difficulties obtaining care in the present could also translate into higher long-term demand for costlier services as untreated conditions worsened.

While policymakers debated various proposals to expand health insurance coverage, none specifically targeted the uninsured population with chronic conditions. Yet because of their medical needs, people with chronic illnesses stood to benefit most from coverage -- particularly those with low incomes. Given the considerable human and economic costs of chronic illness, the impact of coverage proposals on low-income, uninsured people with chronic conditions deserved careful assessment. Health insurance clearly mattered for this vulnerable population.

Sources and Further Reading

Tu, Ha T., and Marie C. Reed. "Options for Expanding Health Insurance for People with Chronic Conditions." Issue Brief No. 50. Center for Studying Health System Change (February 2002).

Wang, Wenke, et al. "Out-Of-Pocket Medical Spending for Care of Chronic Conditions." Health Affairs, Vol. 20, No. 6 (November/December 2001).

Druss, Benjamin G., et al. "Comparing the National Economic Burden of Five Chronic Conditions." Health Affairs, Vol. 20, No. 6 (November/December 2001).

Based on analysis of the HSC Community Tracking Study (CTS) Household Survey, 1998-99.