Approximately 46 million Americans were uninsured in 2006–2007.1
However, measures such as this one are based upon the number of individuals without coverage on a particular day; consequently, these measures record a person as insured even if that individual may have experienced a period without coverage directly preceding or following the day of measurement. The result is an undercount of persons experiencing brief spells uninsured.2
Individuals frequently move into and out of coverage over time,3,4
and persons with chronic conditions and disabilities may be particularly sensitive to the effects of even these brief periods without insurance. A number of factors have caused persons with ongoing health care needs to have difficulty obtaining and maintaining stable coverage, such as taking a job without health benefits, job loss or transition, divorce, means testing, disability determination, or waiting periods for public coverage.5-8
A growing body of research documents how being uninsured can affect persons with chronic conditions,9-13
and other studies have separately examined the experiences that people with disabilities have when uninsured.7,8,14-16
However, these are not mutually exclusive populations, and the extent and effects of insurance coverage gaps in these groups are not well differentiated in the available literature.
Existing research cautions us that insurance coverage is a dynamic process,2-4
but most current studies of these groups employ point-in-time estimates of insurance coverage or limit the analysis to the long-term uninsured, potentially underestimating the extent of coverage interruptions. Furthermore, these are population groups with much to gain (or lose) as health care reform is implemented in the years to come.
Unlike individuals who require simple routine care and screenings, adults with chronic health care needs have conditions that persist over time, sometimes necessitating the continuing use of a range of costly health care services.17
In addition, persons with chronic conditions frequently have multiple long-term conditions18
and may also develop additional acute conditions over time.19
Although this accumulation of medical conditions is well documented in elderly populations,20
roughly half of the working-aged population also has at least 1 chronic condition.21
About a quarter of these persons will also report some degree of disability that may affect work and other types of community participation, as well as such fundamental activities as independently dressing, bathing, or preparing a meal.18,22
Regardless of whether an individual has a single chronic condition or several, or whether that individual has a disability or not, the effort required to manage ongoing health care needs over time can be substantial, particularly in a system as specialized as ours.23,24
Studies of persons with chronic conditions18,19,21
document high utilization rates of many types of care in numerous different settings. Hence, the primary concerns for many persons with chronic conditions and disabilities include how to arrange, coordinate, and pay for care from multiple providers at the same time.18
Indeed, even among the fully insured, out-of-pocket spending rises in a linear fashion with the number of chronic conditions reported.27
In light of these concerns, we investigated the extent of insurance coverage gaps among working-aged adults with chronic conditions and disabilities. Although these populations have historically been studied separately, we used a combined approach because of their shared needs for ongoing health care services. We examined the prevalence of part-year and full-year insurance gaps in 3 subgroups of these adults on the basis of presence and extent of disability. We then analyzed how this instability in coverage could affect access to general medical services and prescription medications, rates of ambulatory health care visits and prescription fills, and out-of-pocket spending for health care services.