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     The following information regarding health insurance
     coverage is provided courtesy of Dr. Gary Greenberg
     on OCC-ENV-MED.
          
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Health Insurance Coverage and Receipt of Preventive Health Services--
United States, 1993
                              
In 1992, an estimated 38.5 million U.S. residents aged less than 65
years did not have health insurance (1). Efforts by states to expand
health-care coverage will require surveillance for and state-specific
information about coverage for acute care and the receipt of
preventive services. This report summarizes state-specific and
aggregated data from the 1993 Behavioral Risk Factor Surveillance
System (BRFSS) regarding the status of health insurance coverage and
the receipt of preventive health services among adults aged 18-64
years. In addition, findings from the analysis of supplemental
questions added to the BRFSS in Minnesota are included that address
health-care utilization, source of health-care coverage, and coverage
of children.

In 1993, the District of Columbia and all states except Wyoming
participated in the BRFSS, a population-based, random-digit-dialed
telephone survey of adults aged greater than or equal to 18 years (2).
All persons responding to the BRFSS questionnaire were asked whether
they had health-care coverage*, which of selected preventive health
services they had received, if they had a usual place of medical care,
and how they perceived their health status. This analysis specifically
examined preventive health services targeted by the national health
objectives for the year 2000 (i.e., cholesterol screening, breast and
7cervical cancer screening, and colorectal cancer screening) (3). The
use of these services, the perception of health status, and absence of
a usual place of medical care were compared between persons who were
insured and uninsured by calculating crude prevalence ratios and
adjusted odds ratios (i.e., adjusted for age, race, education level,
employment status, and income level). For this analysis, sample
estimates were statistically weighted to reflect the
noninstitutionalized civilian population in each state, and standard
errors were calculated using SESUDAAN.

Health Insurance Coverage for Persons Aged 18-64 Years

Of the 102,263 persons who participated in the 1993 BRFSS, 81,794
persons aged 18-64 years responded to the question about health-care
coverage. Of these respondents, 16% reported they were uninsured at
the time of interview (Table 1). The percentages of persons who
reported being uninsured ranged from 7% in Hawaii to 26% in Louisiana
(Table 1). The prevalence of being uninsured was higher among persons
in states in the West (20%; 95% confidence interval [CI]=19%-21%) and
South (19%; 95% CI=18%-19%) than in the Northeast (14%; 95%
CI=13%-15%) or Midwest (12%; 95% CI=11%-13%).**

The prevalence of being uninsured was highest among men (18%), persons
aged 18-24 years (27%), those with less than a high school education
(35%), those with an annual household income less than $10,000 (39%),
blacks (21%), Hispanics (34%), and persons who were unemployed (44%)
(Table 2). Compared with women who were insured, women who were
uninsured were twofold more likely to report having no usual place of
medical care (10% versus 18%), at least 50% less likely to have had
both a mammogram and a clinical breast examination during the previous
2 years (69% versus 35%), and less likely to report having had a
digital rectal examination during the previous 2 years (51% versus
29%) or ever having had a proctoscopy examination (32% versus 22%)
(Table 3). The prevalences of self-perceived health status were
similar among women who were insured and uninsured.

When compared with men who were insured, uninsured men were two times
more likely to report having no usual place of medical care (18%
versus 41%) and half as likely to report having had their cholesterol
checked (65% versus 36%) or having had a digital rectal (51% versus
27%) or a proctoscopy examination (38% versus 20%). The prevalences of
self-perceived health status were similar among men who were insured
and uninsured.

Minnesota-Specific Data for Persons Aged 18-64 Years

The Minnesota Department of Health asked all respondents 12
supplemental questions about health insurance coverage. Among the 2494
persons who were insured, 1852 (75%; 95% CI=73%-77%) reported their
employer was their primary source of coverage for health insurance.
Overall, 9% (95% CI=8%-10%) of employed persons were uninsured and 20%
(95% CI=15%-25%) of those employed in service occupational groups were
uninsured. In addition, 44% (95% CI=37%-50%) of uninsured persons and
21% (95% CI=19%-23%) of insured persons reported no visits to a
physician during the previous year.

Of the 253 persons who were uninsured, 178 (69%; 95% CI=63%-75%)
reported the primary reason they lacked health insurance was cost. In
addition, of the 102 uninsured persons with children, 53 (53%; 95%
CI=35%- 55%) reported that their children did not have health-care
coverage.

Reported by: N Salem, PhD, Minnesota Dept of Health. BRFSS
coordinators S Jackson, MPA, Alabama; P Owen, Alaska; B Bender,
Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff,
MSPH, Colorado; M Adams, MPA, Connecticut; F Breukelman, Delaware; C
Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger,
MPA, Georgia; F Newfield, MPA, Hawaii; C Johnson, MPH, Idaho; B
Steiner, MS, Illinois; R Guest, MPA, Indiana; P Busick, Iowa; M Perry,
Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, MSW, Louisiana; D
Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH,
Massachusetts; H McGee, MPH, Michigan; E Jones, MS, Mississippi; J
Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman,
Nebraska; E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager,
MS, New Jersey; P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New
York; G Lengerich, VMD, North Carolina; D Young, MS, North Dakota; E
Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, Oregon; J
Romano, MPH, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH,
South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R
Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; S
Carswell, MA, Virginia; K Holm, MPH, Washington; F King, West
Virginia; E Cautley, MS, Wisconsin. Behavioral Risk Factor
Surveillance Br, Office of Surveillance and Analysis, National Center
for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: This report documents substantial variation in the
state-specific prevalences of persons who report being uninsured. In
addition, persons who were uninsured were less likely to have recently
received preventive health services or have a regular place of medical
care. The 1993 BRFSS findings are consistent with results from
previous national studies indicating that uninsured persons are less
likely to receive preventive health services (4). Lack of health-care
coverage also has been associated with delayed medical care and use of
fewer medical services (5,6).

The findings in this report indicate that uninsured persons are more
likely to be younger, less educated, of races other than white,
unemployed, and of low income. These persons are less likely to engage
in preventive practices that can be effectively encouraged in the
primary health-care setting. Because lack of insurance is associated
with limited access to important preventive health-care services,
improvements in health insurance coverage through health-care reform
at the state level may improve access to preventive health services.

The state-added questions from Minnesota are assisting in identifying
uninsured groups and estimating the percentage of children who are
uninsured. These findings are critical for targeting specific
populations that are uninsured and developing health-care reform and
managed-care strategies.

The findings in this report are subject to at least three limitations.
First, because the BRFSS includes only households with a telephone,
these findings probably underestimate the prevalence of being
uninsured among persons not residing in households with telephones
(e.g., persons living below the poverty level, less educated persons,
and unemployed persons). Second, nonrespondents or refusals in
households with a telephone may be younger and less educated persons
who are more likely to be uninsured. Third, because estimates are
based on self-reported data, responses cannot be validated and are
subject to recall bias.

The BRFSS can be used to provide routinely available, timely,
state-specific data on health insurance coverage and receipt of
preventive health services that may be used to monitor the progress of
health-care reform efforts in each state. This information may assist
state planners in evaluating progress toward the national health
objectives for the year 2000 related to chronic diseases and disabling
conditions. In addition, the BRFSS enables states to add specific
questions, such as those included in Minnesota, to expand
health-related information for use in planning and evaluating
state-based strategies for all groups.

References

1. Snider S, Boyce S. Sources of health insurance and characteristics
of the uninsured: analysis of the March 1993 Current Population
Survey. Washington, DC: Employee Benefit Research Institute, January
1994. (EBRI special report no. SR-20; issue brief no. 145).

2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data.
In: CDC. Using chronic disease data: a handbook for public health
practitioners. Atlanta: US Department of Health and Human Services,
Public Health Service, CDC, 1992:4-1-4-17.

3. Public Health Service. Healthy people 2000: national health
promotion and disease prevention objectives--full report, with
commentary. Washington, DC: US Department of Health and Human
Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50212.

4. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer
screening among women. Hyattsville, Maryland: US Department of Health
and Human Services, Public Health Service, CDC, NCHS, 1994. (Advance
data no. 254).

5. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care
due to lack of health insurance. JAMA 1988;259:2872-4.

6. Weissmann JS, Stern R, Fielding SL, Epstein AM. Delayed access to
health care: risk factors, reasons, and consequences. Ann Intern Med
1991;114:325- 31.

* All respondents were asked, "Do you have any kind of health care
coverage, including health insurance, prepaid plans such as HMOs
(health maintenance organizations), or government plans such as
Medicare?" Persons who reported having no health-care coverage at the
time of the interview were considered to be uninsured.

** West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana,
Nevada, New Mexico, Oregon, Utah, and Washington; South=Alabama,
Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky,
Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South
Carolina, Tennessee, Texas, Virginia, and West Virginia;
Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania, Rhode Island, and Vermont; and
Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota,
Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin.
 ______________________________________________________________________
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|     and medical aspects of occupational and environmental health.    |
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