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1.  Primary Payer Status Affects Outcomes for Cardiac Valve Operations 
Background
Disparities in healthcare have been reported among various patient populations, and the uninsured and Medicaid populations are a significant focus of current healthcare reform. The objective of this study was to examine the influence of primary payer status on outcomes following cardiac valve operations in the United States.
Methods
From 2003-2007, 477,932 patients undergoing cardiac valve operations were evaluated using discharge data from the Nationwide Inpatient Sample (NIS) database. Records were stratified by primary payer status: Medicare (n=57,249, age=74.0±0.02 yrs), Medicaid (n=5,868, age=41.2±0.13 yrs), Uninsured (n=2,349, age=49.7±0.15 yrs), and Private Insurance (n=31,808, age=53.3±0.04yrs). Multivariate regression models were applied to assess the independent effect of payer status on in-hospital outcomes.
Results
Preoperative patient risk factors were more common among Medicare and Medicaid populations. Unadjusted mortality and complication rates for Medicare (6.9%, 36.6%), Medicaid (5.7%, 31.4%) and Uninsured (5.2%, 31.4%) patient groups were higher compared to Private Insurance groups (2.9%, 29.9%, p<0.001). Moreover, mortality was lowest for patients with Private Insurance for all types of valve operations. Medicaid patients accrued the longest unadjusted hospital length of stay and highest total hospital costs compared to other payer groups (p<0.001). Importantly, after risk adjustment, Uninsured and Medicaid payer status conferred the highest odds of risk adjusted mortality and morbidity compared to Private Insurance status and were higher than those for Medicare.
Conclusions
Uninsured and Medicaid payer status is associated with increased risk adjusted in-hospital mortality and morbidity among patients undergoing cardiac valve operations compared to Medicare and Private Insurance. Further, Medicaid patients accrued the longest hospital stays and highest total costs. Primary payer status should be considered as an independent risk factor during preoperative risk stratification and planning.
doi:10.1016/j.jamcollsurg.2010.12.050
PMCID: PMC3085604  PMID: 21398153
Payer Status; Insurance; Cardiac Valve; Mortality; Outcomes
2.  The Impact of Insurance Status on the Outcomes after Aneurysmal Subarachnoid Hemorrhage 
PLoS ONE  2013;8(10):e78047.
Investigation into the association of insurance status with the outcomes of patients undergoing neurosurgical intervention has been limited: this is the first nationwide study to analyze the impact of primary payer on the outcomes of patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling or microsurgical clipping. The Nationwide Inpatient Sample (2001–2010) was utilized to identify patients; those with both an ICD-9 diagnosis codes for subarachnoid hemorrhage and a procedure code for aneurysm repair (either via an endovascular or surgical approach) were included. Hierarchical multivariate regression analyses were utilized to evaluate the impact of primary payer on in-hospital mortality, hospital discharge disposition, and length of hospital stay with hospital as the random effects variable. Models were adjusted for patient age, sex, race, comorbidities, socioeconomic status, hospital region, location (urban versus rural), and teaching status, procedural volume, year of admission, and the proportion of patients who underwent ventriculostomy. Subsequent models were also adjusted for time to aneurysm repair and time to ventriculostomy; subgroup analyses evaluated for those who underwent endovascular and surgical procedures separately. 15,557 hospitalizations were included. In the initial model, the adjusted odds of in-hospital mortality were higher for Medicare (OR 1.23, p<0.001), Medicaid (OR 1.23, p<0.001), and uninsured patients (OR 1.49, p<0.001) compared to those with private insurance. After also adjusting for timing of intervention, Medicaid and uninsured patients had a reduced odds of non-routine discharge (OR 0.75, p<0.001 and OR 0.42, p<0.001) despite longer hospital stays (by 8.35 days, p<0.001 and 2.45 days, p = 0.005). Variations in outcomes by primary payer–including in-hospital post-procedural mortality–were more pronounced for patients of all insurance types who underwent microsurgical clipping. The observed differences by primary payer are likely multifactorial, attributable to varied socioeconomic factors and the complexities of the American healthcare delivery system.
doi:10.1371/journal.pone.0078047
PMCID: PMC3812119  PMID: 24205085
3.  Primary Payer Status is Associated with Mortality and Resource Utilization for Coronary Artery Bypass Grafting 
Circulation  2012;126(11 Suppl 1):S132-S139.
Background
Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following coronary artery bypass grafting (CABG) in the United States is dependent upon primary payer status.
Methods
From 2003–2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, Uninsured, and Private Insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes.
Results
Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%) and Uninsured (1.9%) patients were higher compared to Private Insurance patients (1.1%, p<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9±0.04 days) and shortest for Private Insurance patients (8.0±0.01 days, p<0.001). Medicaid patients accrued the highest unadjusted total costs ($113,380±386, p<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (OR=1.82, p<0.001) and Uninsured (OR=1.62, p<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (p<0.001).
Conclusions
Medicaid and Uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.
doi:10.1161/CIRCULATIONAHA.111.083782
PMCID: PMC3448930  PMID: 22965973
Payer Status; Insurance; CABG; Mortality; Outcomes
4.  An exploration of the complex relationship of socioecologic factors in the treatment and outcomes of acute myocardial infarction in disadvantaged populations. 
Health Services Research  2001;36(4):711-732.
OBJECTIVE: To examine the relationship of patients' socioeconomic status (SES) as measured by race, health insurance status, and median income by zip code to in-hospital mortality of acute myocardial infarction (AMI), paying special attention to patients with multiple unfavorable socioeconomic risk factors. DATA SOURCES/STUDY SETTING: The data set was abstracted from patient-level hospital discharges in the Nationwide Inpatient Sample, Release 3, 1994. A total of 95,971 AMI discharges in 11 states were extracted. STUDY DESIGN: The risk adjustment methodology was adapted from the California Hospital Outcomes Project. Risk factors included demographic and clinical characteristics. Patients in double jeopardy had inferior insurance status and lived in poorer neighborhoods. PRINCIPAL FINDINGS: Compared with patients with health care coverage under Medicare and private insurance uninsured AMI patients had the highest risk-adjusted mortality odds and Medicaid AMI patients had the second highest odds. Probably because of the modest association of median income by zip code areas with mortality odds, the double jeopardy phenomenon was not observed. However, compared to patients who had two favorable SES attributes, patients who carried two unfavorable SES attributes had much higher mortality risk, more comorbidities, longer length of stay, and higher total hospital charges, while they received fewer AMI specialized procedures. Race did not seem to be a significant factor after adjustment for other SES attributes. CONCLUSIONS: SES is significantly related to the mortality of AMI patients. The disadvantaged patients receive fewer specialized procedures, possibly because of their higher levels of severity and financial barriers. The variation in mortality between patients who had favorable and unfavorable SES becomes wider when multiple socioeconomic risks are borne by the latter.
PMCID: PMC1089253  PMID: 11508636
5.  Post-Operative Mortality after Surgery for Brain Tumors Differs by Insurance Status in the United States 
Objective
Determine whether being uninsured is associated with higher in-hospital postoperative mortality when undergoing surgery in the United States for a brain tumor.
Hypothesis
Uninsured patients may experience poor surgical outcomes due to suboptimal care, poor overall health, or impaired healthcare access.
Design
Retrospective cohort study utilizing the Nationwide Inpatient Sample (NIS), 1999 to 2008.
Setting
The NIS contains all inpatient records from a stratified sample of 20% of hospitals in 37 states.
Patients
28,582 patients, ages 18 to 65 years, who underwent craniotomy for a brain tumor. Three groups were studied: privately insured, Medicaid recipients, and uninsured.
Main Outcome Measure
In-hospital postoperative death. Associations between this outcome and insurance status were examined within the full cohort and within the subset of patients with no co-morbidity using Cox proportional hazards models. These models were stratified by hospital to control for any clustering effects that could arise from differing access to care.
Results
In the unadjusted analysis, the mortality rate for privately insured patients was 1.28% (95% confidence interval [CI], 1.13%-1.42%), compared to 2.60% for uninsured patients (CI, 1.87%-3.33%, P<.001), and 2.33% for Medicaid recipients (CI, 1.85%-2.82%, P<.001). After adjusting for patient characteristics and stratifying by hospital in patients with no co-morbidity, uninsured patients still had a higher risk of experiencing in-hospital death (hazard ratio 2.62, CI, 1.11-6.14, P=.027) compared with privately-insured patients. In this adjusted analysis, the disparity was not conclusively present in Medicaid recipients (hazard ratio 2.03, CI, 0.97-4.23, P=.06).
Conclusions
Uninsured patients who underwent craniotomy for a brain tumor experienced the highest in-hospital mortality. Differences in overall health or healthcare access do not fully account for this disparity.
doi:10.1001/archsurg.2012.1459
PMCID: PMC3571758  PMID: 23165616
6.  The association between insurance status and in-hospital mortality on the public medical wards of a Kenyan referral hospital 
Global Health Action  2014;7:10.3402/gha.v7.23137.
Background
Observational data in the United States suggests that those without health insurance have a higher mortality and worse health outcomes. A linkage between insurance coverage and outcomes in hospitalized patients has yet to be demonstrated in resource-poor settings.
Methods
To determine whether uninsured patients admitted to the public medical wards at a Kenyan referral hospital have any difference in in-hospital mortality rates compared to patients with insurance, we performed a retrospective observational study of all inpatients discharged from the public medical wards at Moi Teaching and Referral Hospital in Eldoret, Kenya, over a 3-month study period from October through December 2012. The primary outcome of interest was in-hospital death, and the primary explanatory variable of interest was health insurance status.
Results
During the study period, 201 (21.3%) of 956 patients discharged had insurance. The National Hospital Insurance Fund was the only insurance scheme noted. Overall, 211 patients (22.1%) died. The proportion who died was greater among the uninsured compared to the insured (24.7% vs. 11.4%, Chi-square=15.6, p<0.001). This equates to an absolute risk reduction of 13.3% (95% CI 7.9–18.7%) and a relative risk reduction of 53.8% (95% CI 30.8–69.2%) of in-hospital mortality with insurance. After adjusting for comorbid illness, employment status, age, HIV status, and gender, the association between insurance status and mortality remained statistically significant (adjusted odds ratio (AOR)=0.40, 95% CI 0.24–0.66) and similar in magnitude to the association between HIV status and mortality (AOR=2.45, 95% CI 1.56–3.86).
Conclusions
Among adult patients hospitalized in a public referral hospital in Kenya, insurance coverage was associated with decreased in-hospital mortality. This association was comparable to the relationship between HIV and mortality. Extension of insurance coverage may yield substantial benefits for population health.
doi:10.3402/gha.v7.23137
PMCID: PMC3925809  PMID: 24560256
health insurance; disparities; hospital medicine; Africa
7.  Health Care Insurance, Financial Concerns, and Delays to Hospital Presentation in Acute Myocardial Infarction 
Context
Little is known about how health insurance status affects decisions to seek care during emergency medical conditions like acute myocardial infarction (AMI).
Objective
To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI.
Design, Setting and Patients
Multicenter, prospective registry of 3721 AMI patients enrolled between April, 2005 and December, 2008 from 24 U.S. hospitals. Health insurance status was categorized as uninsured, insured with financial concerns about accessing care, and insured without financial concerns. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews.
Main Outcome Measure
Prehospital delay times (≤2 hours, >2 to 6 hours, >6 hours), adjusted for demographic, clinical, social and psychological factors using hierarchical ordinal regression models.
Results
Of 3,721 patients, 738 (19.8%) were uninsured, and 689 (18.5%) were insured with financial concerns, and 2294 (61.7%) were insured without financial concerns. Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI, with prehospital delays >6 hours among 48.6% of uninsured patients, 44.6% of insured patients with financial concerns, and 39.3% of insured patients without financial concerns, as compared with prehospital delays of <2 hours among 27.5%, 33.5%, and 36.6% of those who were uninsured, insured with financial concerns, and insured without financial concerns, respectively (P <.001). After adjusting for potential confounders, both insurance with financial concerns and lack of insurance were associated with prehospital delays: insurance without financial concerns (reference); insurance with financial concerns, adjusted odds ratio [OR)], 1.21; 95% confidence interval [CI]: 1.05-1.41, P=.01; no insurance, adjusted OR 1.38, 95% CI: 1.17-1.63, P <.001.
Conclusions
Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
doi:10.1001/jama.2010.409
PMCID: PMC3020978  PMID: 20388895
8.  Insurance type and sepsis-associated hospitalizations and sepsis-associated mortality among US adults: A retrospective cohort study 
Critical Care  2011;15(3):R130.
Introduction
Socio-demographic and clinical factors associated with increased sepsis risk, including older age, non-white race and specific co-morbidities, are more common among patients with Medicare or Medicaid or no health insurance. We hypothesized that patients with Medicare and/or Medicaid or without health insurance have a higher risk of sepsis-associated hospitalization or sepsis-associated death than those with private health insurance.
Methods
We performed a retrospective cohort study of records from the 2003 Nationwide Inpatient Sample. We stratified the study cohort by Medicare age-qualification (18 to 64 and 65+ years old). We examined the association between insurance category and sepsis diagnosis and death among admissions involving sepsis. We used validated diagnostic codes to determine the presence of sepsis, co-morbidities and organ dysfunction and to provide risk-adjustment.
Results
Among patients 18 to 64 years old, those with Medicaid (adjusted odds ratio (AOR) 1.50), Medicare (AOR 1.96), Medicaid + Medicare (AOR 2.22) and the uninsured (AOR 1.18) had significantly higher risk-adjusted odds of a sepsis-associated admission than those with private insurance (all P < 0.0001). Those with Medicaid (AOR 1.17, P < 0.001) and those without insurance (AOR 1.45, P < 0.001) also had significantly higher adjusted odds of sepsis-associated hospital mortality than those with private insurance. Among those 65+ years old, those with Medicaid (AOR 1.43), Medicare alone (AOR 1.13) or Medicaid + Medicare (AOR 1.62) had significantly higher risk-adjusted odds of sepsis-associated admission than those with private insurance and Medicare (all P < 0.0001). Among sepsis patients 65+, uninsured patients had significantly higher risk-adjusted odds (AOR 1.45, P = 0.0048) and those with Medicare alone had significantly lower risk-adjusted odds (AOR 0.92, P = 0.0072) of hospital mortality than those with private insurance and Medicare. Lack of health insurance remained associated with sepsis-associated mortality after stratification of hospitals into quartiles based on rates of sepsis-associated admissions or mortality in both age strata.
Conclusions
Risks of sepsis-associated hospitalization and sepsis-associated death vary by insurance. These increased risks were not fully explained by the available socio-demographic factors, co-morbidities or hospital rates of sepsis-related admissions or deaths.
doi:10.1186/cc10243
PMCID: PMC3218996  PMID: 21605427
9.  An Official American Thoracic Society Systematic Review: The Association between Health Insurance Status and Access, Care Delivery, and Outcomes for Patients Who Are Critically Ill 
Rationale: One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care.
Objectives: To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status.
Methods: Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate.
Measurements and Main Results: From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55–0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0–11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46–13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12–7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01–1.33). Patients in managed care systems had 14.3% (95% CI, 11.5–17.2) fewer procedures in intensive care, but were also less likely to receive “potentially ineffective” care. Differences in unmeasured confounding factors may contribute to these findings.
Conclusions: Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.
doi:10.1164/rccm.200902-0281ST
PMCID: PMC3269233  PMID: 20430926
insurance; disparities; payer; critical care; intensive care; access; outcome; Medicare; managed care; Medicaid
10.  The Impact of Health Insurance Status on the Survival of Patients With Head and Neck Cancer 
Cancer  2010;116(2):476-485.
BACKGROUND
In 2006, it was estimated that 47 million people in the United States are without insurance. Studies have shown that patients who are uninsured or are insured by Medicaid are more likely to present with more advanced cancer. The objective of this study was to examine whether cancer recurrence and mortality of patients diagnosed with squamous cell carcinoma of the head and neck are associated with insurance status, after adjusting for known cancer risk factors. The main outcome measures were overall survival and relapse-free survival.
METHODS
Retrospective cohort of patients with a biopsy-proven primary squamous cell carcinoma of the oral cavity, pharynx, or larynx diagnosed or treated at the University of Pittsburgh Medical Center between 1998 and 2007. Patients were stratified by their insurance status, including private insurance, uninsured/Medicaid, Medicare disability (Medicare under age 65), and Medicare 65 years +. Covariates included age, gender, race, smoking status, alcohol consumption, anatomic tumor site, treatment, stage at diagnosis, and occupational prestige score. Cox proportional hazards regression was used to estimate the effect of insurance status on overall survival, relapse-free survival, tumor stage, and lymph node involvement.
RESULTS
A total of 1231 patients were included in the analysis. Patients with Medicaid/uninsured (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.07-2.11) and Medicare disability (HR, 1.69; 95% CI, 1.16-2.48) had significantly lower overall survival compared with patients with private insurance; the result was independent of variables known to affect outcome, such as alcohol and tobacco use. For all squamous cell carcinoma of the head and neck (SCCHN) cancer sites, Medicaid and uninsured patients were significantly more likely to present with an advanced stage tumor at diagnosis (odds ratio [OR] = 2.94; 95% CI, 1.72-5.01) and to present with at least 1 positive lymph node (OR = 1.84; 95% CI, 1.16-2.90) compared with patients with private insurance.
CONCLUSIONS
Patients with Medicaid/uninsured and Medicare disability were at increased risk of death after a diagnosis of SCCHN when compared with patients with private insurance, after adjustment for age, gender, race, smoking, alcohol use, site, socioeconomic status, treatment, and cancer stage.
doi:10.1002/cncr.24774
PMCID: PMC3085979  PMID: 19937673
retrospective cohort; cancer outcome; risk factors; epidemiology
11.  Effect of insurance status on postacute care among working age stroke survivors 
Neurology  2012;78(20):1590-1595.
Objective:
Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors.
Methods:
A retrospective cross-sectional study of ischemic stroke survivors under age 65 from the 2004–2006 Nationwide Inpatient Sample was conducted. Hierarchical logistic regression models controlling for patient and hospital-level factors were used. The primary outcome was utilization of any institutional postacute care (inpatient rehabilitation or skilled nursing facilities) following hospital admission for ischemic stroke. Intensity of rehabilitation was explored by comparing utilization of inpatient rehabilitation facilities and skilled nursing facilities.
Results:
Of the 33,917 working age stroke survivors, 19.3% were uninsured, 19.8% were Medicaid enrollees, and 22.8% were discharged to institutional postacute care. Compared to those privately insured, uninsured stroke survivors were less likely (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.47–0.59) while stroke survivors with Medicaid were more likely to utilize any institutional postacute care (AOR = 1.40, 95% CI 1.27–1.54). Among stroke survivors who utilized institutional postacute care, uninsured (AOR = 0.48, 95% CI 0.36–0.64) and Medicaid stroke survivors (AOR = 0.27, 95% CI 0.23–0.33) were less likely to utilize an inpatient rehabilitation facility than a skilled nursing facility compared to privately insured stroke survivors.
Conclusions:
Insurance status among working age acute stroke survivors is independently associated with utilization and intensity of institutional postacute care. This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured.
doi:10.1212/WNL.0b013e3182563bf5
PMCID: PMC3348849  PMID: 22551730
12.  Insurance status and the transfer of hospitalized patients: an observational study 
Annals of internal medicine  2014;160(2):81-90.
Background
There is little objective evidence to support concerns that patients are transferred between hospitals based upon insurance status.
Objective
To examine the relationship between patients’ insurance coverage and inter-hospital transfer.
Design
We analyzed data from the 2010 National Inpatient Sample.
Patients
All patients aged 18-64 years discharged alive from U.S. acute care hospitals with one of five common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, skin or subcutaneous infection).
Measurements
For each diagnosis, we compared the proportion of hospitalized patients who were transferred to another acute-care hospital based upon insurance coverage (private, Medicare, Medicaid, and uninsured). We used logistic regression to estimate the odds of transfer for uninsured patients (reference category- privately insured) while adjusting for patient and hospital level factors. All analyses incorporated sampling and post-stratification weights.
Results
Among 315,748 patients discharged from 1051 hospitals with our five diagnoses, the percentage of patients transferred to another acute-care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses uninsured patients were significantly less likely to be transferred for three diagnoses (p<.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for the four diagnoses: biliary tract disease (Odds Ratio (OR) 0.73 (95% Confidence interval (CI) 0.55-0.96)); chest pain (OR 0.63 (CI 0.44-0.89)); septicemia (OR 0.76 (CI 0.64-0.91)); and skin infections (OR 0.64 (CI 0.46-0.89)). Women were significantly less likely to be transferred than men for all diagnoses.
Limitations
This analysis relied on administrative data and lacked clinical detail.
Conclusions
Uninsured patients (and women) were significantly less likely to undergo inter-hospital transfer. Differences in transfer rates may contribute to healthcare disparities.
PMCID: PMC4157678  PMID: 24592493
13.  Uninsured and unstably insured: the importance of continuous insurance coverage. 
Health Services Research  2000;35(1 Pt 2):187-206.
OBJECTIVE: To examine the importance of continuous health insurance for access to care by comparing the access and cost experiences of insured adults with a recent time uninsured to the experiences of currently uninsured adults and experiences of adults with no time uninsured within a reference time period (continuously insured). DATA SOURCES: Adults ages 18-64. Data draw from three different survey databases: the Robert Wood Johnson Foundation 1996-1997 Community Tracking Survey, the Kaiser/Commonwealth 1997 National Survey of Health Insurance, and the 1995-1997 Kaiser/Commonwealth State Low Income Surveys. STUDY DESIGN: The study groups individuals into three insurance categories based on respondents' reports of insurance coverage within a reference time period: continuously insured; insured when surveyed but with recent time uninsured; and currently uninsured. In the two Kaiser/Commonwealth surveys the recently uninsured group included any insured respondent with a time uninsured in the past two years. In the Community Tracking Survey, the recently uninsured group included any insured respondent with a time uninsured in the past year. Measures of access include foregoing health care when needed, usual source of care, use of health care services, difficulties paying for medical care, and satisfaction with care. DATA COLLECTION: All three surveys were conducted primarily by telephone. The Community Tracking Survey drew from 60 community sites, with an additional random national sample. The Kaiser/Commonwealth National Survey was a random national sample; the Kaiser/Commonwealth State Low Income Surveys included adults ages 18-64 with incomes at or below 250 percent of poverty in seven states: Minnesota, Oregon, Tennessee, Florida, Texas, New York, and California. PRINCIPAL FINDINGS: Compared to the continuously insured, those insured but with a recent time uninsured were at high risk of going without needed care and of having problems paying medical bills. This group was two to three times as likely as those with continuous coverage to report access problems. Rates of access and cost problems reported by insured adults with a recent time uninsured neared levels reported by those who were uninsured at the time of the survey. These two groups also rated care received more negatively than did adults with continuous insurance coverage. In general, the access gap between persons insured and uninsured widened as a result of distinguishing insured adults with a recent time uninsured from insured adults with no time uninsured. CONCLUSION: Studies that focus on current insurance status alone will underestimate the extent to which having a time uninsured during the year contributes to access difficulties and undermines quality of care, and will underestimate the proportion of the population at risk because they are uninsured. Policy reforms are needed to maintain continuous insurance coverage and avoid spells uninsured. Currently uninsured and unstably insured adults are both at high risk.
PMCID: PMC1089095  PMID: 10778809
14.  Insurance Status Predicts Access to Care and Outcomes of Vascular Disease 
Objective
To determine if insurance status predicts severity of vascular disease at the time of treatment or outcomes following intervention.
Methods
Hospital discharge databases from Florida and New York from 2000–2005 were analyzed for lower extremity revascularization (LER, n=73,532), carotid revascularization (CR, n=116,578), or abdominal aortic aneurysm repair (n=35,593), using ICD-9 codes for diagnosis and procedure. The indications for intervention as well as the post-operative outcomes were examined assigning insurance status as the independent variable. Patients covered under a variety of commercial insurers, as well as Medicare, were compared to those who either had no insurance or were covered by Medicaid.
Results
Patients without insurance or with Medicaid were at significantly greater risk of presenting with a ruptured abdominal aortic aneurysm (AAA) compared to insured (non-Medicaid) patients; while insurance status did not seem to impact post-operative mortality rates for elective and ruptured AAA repair. The uninsured or Medicaid recipients presented with symptomatic carotid disease nearly twice as often as the insured, but stroke rates after CR did not differ significantly based on insurance status. Patients with Medicaid or without insurance were more likely to present with limb threatening ischemia than claudication. In contrast to AAA repair and CR, the outcomes of LER were worse in the uninsured and Medicaid beneficiaries, who had higher rates of post-revascularization amputation compared to the insured (non-Medicaid) group.
Conclusion
Insurance status predicts disease severity at the time of treatment, but once treated, the outcomes are similar among insurance categories, with the exception of lower extremity revascularization. This data suggests inferior access to preventative vascular care in the Medicaid and the uninsured populations.
doi:10.1016/j.jvs.2008.05.010
PMCID: PMC2582051  PMID: 18586449
15.  Effect of Insurance Status on the Stage of Breast and Colorectal Cancers in a Safety-Net Hospital 
Journal of Oncology Practice  2012;8(3 Suppl):16s-21s.
In a safety-net hospital, patients with Medicaid have rates of advanced-stage cancer similar to those of patients with other types of insurance; however, patients with no insurance have significantly higher rates of advanced disease.
Purpose:
Screening can increase early detection and reduce rates of advanced-stage cancer. Uninsured patients have been shown to have lower rates of screening. Previous studies have shown that uninsured patients and patients with Medicaid present with more advanced stages of cancer. The aim of this study was to measure the effect of insurance status in the setting of a safety-net hospital.
Methods:
Patients in our tumor registry with a diagnosis of breast or colorectal cancer between 2001 and 2010 were included. On the basis of their insurance status, they were divided into the following groups: Medicaid, Medicare, Medicare age < 65 years, commercial, uninsured, and unknown. Cancer stage was recorded for each patient, with stages III and IV considered advanced disease. The primary end point was the rate of advanced disease in each patient group.
Results:
A total of 910 patients were included in the study: 836 (91.9%) insured, 54 (5.9%) uninsured, and 20 (2.2%) unknown. Of the insured patients, 301 (36.0%) had Medicaid. Two hundred thirty-seven (30.7%) of 836 insured patients had advanced disease, compared with 27 (50.0%) of 54 uninsured patients (odds ratio, 1.63; P = .003). Of patients with Medicaid, 83 (27.6%) of 301 had advanced disease, which was not statistically different from patients with other insurance.
Conclusion:
In a safety-net hospital, patients with Medicaid had rates of advanced-stage cancer similar to those in patients with other types of insurance. However, patients with no insurance had significantly higher rates of advanced disease. This has significant ramifications in view of the new health care law, which will convert many patients from being uninsured to having Medicaid.
doi:10.1200/JOP.2012.000542
PMCID: PMC3348593  PMID: 22942818
16.  Reasons Why Patients Remain Uninsured after Massachusetts’ Health Care Reform: A Survey of Patients at a Safety-Net Hospital 
ABSTRACT
BACKGROUND
Following the 2006 Massachusetts health care reform, an estimated 316,492 residents remain uninsured. However, there have been no published studies that examine why Massachusetts residents remain uninsured four years into health reform.
OBJECTIVE
To describe the characteristics of uninsured patients seeking acute medical care in Massachusetts after implementation of health care reform and reasons for lacking insurance.
DESIGN AND PARTICIPANTS
We performed an in-person survey of a convenience sample of patients visiting the emergency department of the state’s second largest safety net hospital between July 25, 2009 and March 20, 2010. We interviewed 431 patients age 18–64, 189 of whom were uninsured.
MAIN MEASURES
Demographic and clinical characteristics, employment and insurance history, reasons for lacking insurance and views of the state’s new “individual mandate”.
KEY RESULTS
The uninsured were largely employed (65.9%), but only a quarter (25.1%) of the employed uninsured had access to employer-sponsored insurance. The majority qualified for subsidized insurance (85.7% earned ≤300% of the federal poverty level), yet many reported being unable to find affordable insurance (32.7%). Over a third (35.2%) were uninsured because they had lost insurance due predominantly to job loss or policy cancellation. For nearly half of the uninsured (48.6%), the individual mandate had motivated them to try to find insurance, but they were unable to find insurance they could afford.
CONCLUSIONS
After full implementation of the Massachusetts health reform, those remaining without insurance are largely the working poor who do not have access to, or cannot afford, either employer sponsored insurance or state subsidized insurance.
doi:10.1007/s11606-011-1868-5
PMCID: PMC3270239  PMID: 21922156
uninsured; health reform; health policy; safety-net institutions; health insurance
17.  Usual Source of Care and Unmet Need Among Vulnerable Children: 1998–2006 
Pediatrics  2009;123(2):e214-e219.
OBJECTIVE
The purpose of this work was to identify the proportions of publicly (Medicaid and State Child Health Insurance Program) insured and uninsured children who did not identify a usual source of care from 1998 to 2006, spanning the State Children’s Health Insurance Program (1997 to present) and the President’s Health Center Initiative (2002 to present), and to characterize unmet medical need as it relates to insurance and a usual source of care for publicly insured and uninsured children.
METHODS
We conducted a secondary data analysis of multiple years of the National Health Interview Survey. We identified the proportion of publicly insured and uninsured children aged 0 to 17 years who did not identify a usual source of care and stratified according to the site of care. We described the odds of reporting an unmet medical need according to insurance status and usual source of care, compared with privately insured children with a usual source of care. Sample weights were used to derive national estimates.
RESULTS
From 1998 through 2006, there were significant increases in the proportions of children enrolled in Medicaid (16.7%–24.5%) and the State Child Health Insurance Program (2.0%–5.3%). The proportion of uninsured children has remained stable from 2002 to 2006 at ~10%. However, the proportion of uninsured reporting no usual source of care increased from 17.8% to 23.3%. Hispanic children had significant increases in the proportions of the uninsured and reporting no usual source of care by 2006. Hispanics constituted the largest proportion in both groups. Uninsured children and children without a usual source of care reported the highest odds of unmet need. Among the insured, publicly insured children had twice the odds of reporting an unmet need compared with privately insured children.
CONCLUSIONS
During the State Child Health Insurance Program and the President’s Health Center Initiative, growing proportions of uninsured children reported no usual source of care. Unmet medical need was the highest for the uninsured and those without a usual source of care. These findings suggest that initiatives designed to improve access to care must combine broadened insurance coverage with enhanced access to usual sources of care.
doi:10.1542/peds.2008-2454
PMCID: PMC2787198  PMID: 19171573
usual source of care; Medicaid; SCHIP; uninsured; children; health center
18.  Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties 
CONTEXT
Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities.
PURPOSE
We compared uninsured ED visit rates between rural counties in Georgia which have a community health center clinic site vs. counties without a CHC presence.
METHODS
We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003-2005. Counties were classified as having a CHC presence if a federally funded (Section 330) community health center had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and presence of a CHC. To assure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits.
FINDINGS
Counties without a community health center primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio=1.33, 95% CI=1.11-1.59). Higher ED visit rates remained significant (RR=1.21, 95% CI=1.02-1.42) after adjustment for percent of population below poverty level, percent black, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR=1.22, 95% CI=1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR=1.06, 95% CI=0.92-1.22).
CONCLUSIONS
Absence of a community health center is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.
doi:10.1111/j.1748-0361.2009.00193.x
PMCID: PMC2711875  PMID: 19166556
Primary Care; Access to Care; Emergency Department; Community Health Centers; Safety Net; Uninsured
19.  Pressures on safety net access: the level of managed care penetration and uninsurance rate in a community. 
Health Services Research  1999;34(1 Pt 2):255-270.
OBJECTIVE: To examine the effects of managed care penetration and the uninsurance rate in an area on access to care of low-income uninsured persons and to compare differences in access between low-income insured and uninsured persons across these different market areas. DATA SOURCES: Primarily the Community Tracking Study household survey. Other market-level data were obtained from the Community Tracking Study physician survey, American Hospital Association annual survey of hospitals, Area Resource File, HCFA Administrative Data, Bureau of Primary Care data on Community Health Centers. STUDY DESIGN: Individuals are grouped based on the level of managed care penetration and uninsurance rate in the site where they reside. Measures of managed care include overall managed care penetration in the site, and the level of Medicaid managed care penetration in the state. Uninsurance rate is defined as the percentage of people uninsured in the site. Measures of access include the percentage with a usual source of care, percentage with any ambulatory care use, and percentage of persons who reported unmet medical care needs. Estimates are adjusted to control for other confounding factors, including both individual and market-level characteristics. DATA COLLECTION: A survey, primarily telephoned, of households concentrated in 60 sites, defined as metropolitan statistical areas and nonmetropolitan areas. PRINCIPAL FINDINGS: Access to care for low-income uninsured persons is lower in states with high Medicaid managed care penetration, compared to uninsured persons in states with low Medicaid managed care penetration. Access to care for low-income uninsured persons is also lower in areas with high uninsurance rates. The "access gap" (differences in access between insured and uninsured persons) is also larger in areas with high Medicaid managed care penetration and areas with high uninsurance rates. CONCLUSIONS: Efforts to achieve cost savings under managed care may result in financial pressures that limit cross-subsidization of care to the medically indigent, particularly for those providers who are heavily dependent on Medicaid revenue. High demand for care (as reflected in high uninsurance rates) may further strain limited resources for indigent care, further limiting access to care for uninsured persons.
PMCID: PMC1088999  PMID: 10199673
20.  Effects of being uninsured on ethnic minorities' management of chronic illness 
Western Journal of Medicine  2001;175(1):19-23.
Objective To compare the effectiveness with which insured and uninsured persons with chronic illnesses managed their health care. Design Recruited volunteers diagnosed with a variety of chronic illnesses who underwent 3 semistructured interviews in a 1-year period. Setting Volunteers were recruited through referrals, flyers, and face-to-face contacts from community health clinics, senior centers, acute care hospitals, and home care services in 2 urban counties in California between December 1997 and December 2000. Participants A total of 297 persons between the ages of 23 and 97 years (35% African American, 33% Latino, and 32% Filipino American), of whom 42 (14%) had no health insurance. Main outcome measures Qualitative analysis of interview data compared insured and uninsured respondents on a series of components of chronic illness management, including control over illness, frequency of health crises, procuring medication, use of medication, understanding of the illness, knowledge of self-care measures, and awareness of risk factors. Whether respondents were under the care of a regular physician was also assessed. Results Compared with insured respondents, uninsured respondents were much less effective at managing their illnesses. The uninsured had poorly controlled illnesses, frequent health crises, difficulty procuring medication, used medication incorrectly, demonstrated poor understanding of their illness, and displayed little knowledge of self-care measures or risk awareness. They rarely had a regular physician or attended a specific health clinic. Conclusions The findings suggest that not only did uninsured persons with chronic health conditions lack adequate health care, their illnesses were also poorly controlled. Inadequately educated about their health, uninsured persons lacked the information, insight, and tools that would have allowed them to manage their illnesses more effectively.
PMCID: PMC1071457  PMID: 11431394
21.  Understanding the demographic characteristics and health of medically uninsured patients 
Canadian Family Physician  2013;59(6):e276-e281.
Abstract
Objective
To determine demographic and diagnostic information about the medically uninsured patient population and compare it with that of the medically insured patient population at a primary care centre.
Design
Medical chart audit.
Setting
Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont.
Participants
Medically uninsured patients who were treated in the Department of Family and Community Medicine at St Michael’s Hospital from 2005 to 2009, as well as randomly selected patients who were insured through the Ontario Health Insurance Program.
Main outcome measures
The following information was obtained from patients’ medical charts: patient’s age, sex, and household income; if the patient had a specific diagnosis (ie, hypertension, type 2 diabetes mellitus, HIV, tuberculosis, substance addiction, or mental health disorder); if the patient accessed a specific category of primary care (ie, prenatal care or routine pediatric care); and the reason for the patient’s uninsured status.
Results
There was no significant difference in the mean age and sex distribution of insured and uninsured patients. The uninsured group had a significantly lower mean household income (P = .02). With the exception of HIV, there was no significant difference in the prevalence of the specific diagnoses studied or in the prevalence of accessing specific categories of primary care between insured and uninsured patients (P > .05). The prevalence of HIV was significantly greater in the uninsured group (24%) than in the insured group (4%) (P = .004). The largest proportion of uninsured patients lacked health insurance owing to the landed immigrant health insurance waiting period (27%), followed by individuals without permanent resident status in Canada (22%). A subgroup analysis of the uninsured, HIV-positive population revealed that the largest proportion of individuals (36%) lacked health insurance because they had no permanent resident status in Canada.
Conclusion
Uninsured and insured patients at the primary care centre did not differ significantly with respect to age and sex distribution; prevalence of hypertension, type 2 diabetes mellitus, tuberculosis, substance addiction, or mental health disorder; or the proportion who sought prenatal or routine pediatric care. The landed immigrant 3-month waiting period was the most common reason that uninsured patients lacked health insurance. Uninsured patients in this study lived in lower-income areas than insured patients did. This, combined with the increased prevalence of HIV in the uninsured group, might lead to a large number of uninsured, HIV-positive patients delaying seeking treatment and might have negative implications for public health.
PMCID: PMC3681470  PMID: 23766066
22.  Treatment Differences by Health Insurance Among Outpatients with Coronary Artery Disease: Insights from the NCDR® 
Objectives
To compare treatment rates by insurance status for 5 quality-of-care indicators for coronary artery disease (CAD) care related to medication treatment.
Method
Within the NCDR's PINNACLE Registry, we identified 60,814 outpatients with CAD from 30 U.S. practices. Hierarchical modified Poisson regression models with practice site as a random effect were used to study the association between health insurance (no insurance, public or private health insurance) and 5 CAD quality measures.
Results
Of 60,814 patients, 5716 (9.4%) patients were uninsured and 11,962 (19.7%) had public insurance, whereas 43,136 (70.9%) were privately insured. After accounting for exclusions, uninsured patients with CAD were 9%, 12%, and 6% less likely to receive treatment with beta-blocker, ACE-I/ARB, and lipid lowering therapy, respectively, than privately insured patients, whereas patients with public insurance were 9% less likely to be prescribed ACE-I/ARB therapy. Most differences by insurance status were attenuated after adjusting for the site providing care. For example, whereas uninsured patients with left ventricular dysfunction and CAD were less likely to receive ACE-I/ARB therapy (unadjusted RR=0.88; 95% CI 0.84-0.93), this difference was eliminated after adjustment for site (adjusted RR=0.95; 95% CI 0.88-1.03; P=0.18).
Conclusions
Within this national outpatient cardiac registry, uninsured patients were less likely to receive evidence-based medications for CAD. These disparities were explained by the site providing care. Efforts to reduce treatment differences by insurance status among cardiac outpatients may additionally need to focus on improving rates of evidence-based treatment at sites with high proportions of uninsured patients.
doi:10.1016/j.jacc.2012.11.058
PMCID: PMC3641586  PMID: 23375933
Quality of Care; Disparities; Cardiovascular; Outpatient Care
23.  Race and Insurance Disparities in Discharge to Rehabilitation for Patients with Traumatic Brain Injury 
Journal of Neurotrauma  2013;30(24):2057-2065.
Abstract
Post-acute inpatient rehabilitation services are associated with improved functional outcomes among persons with traumatic brain injury (TBI). We sought to investigate racial and insurance-based disparities in access to rehabilitation. Data from the Nationwide Inpatient Sample from 2005–2010 were analyzed using standard descriptive methods and multivariable logistic regression to assess race- and insurance-based differences in access to inpatient rehabilitation after TBI, controlling for patient- and hospital-level variables. Patients with moderate to severe TBI aged 18–64 years with complete data on race and insurance status discharged alive from inpatient care were eligible for study. Among 307,675 TBI survivors meeting study criteria and potentially eligible for discharge to rehabilitation, 66% were white, 12% black, 15% Hispanic, 2% Asian, and 5% other ethnic minorities. Most whites (70%), Asians (70%), blacks (59%), and many Hispanics (49%) had insurance. Compared with insured whites, insured blacks had reduced odds of discharge to rehabilitation (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.75–0.95). Also, insured Hispanics (OR 0.52; 95% CI 0.44–0.60) and insured Asians (OR 0.54; 95% CI 0.39–0.73) were less likely to be discharged to rehabilitation than insured whites. Compared with insured whites, uninsured whites (OR 0.57; 95% CI 0.51–0.63), uninsured blacks (OR 0.33; 95% CI 0.26–0.42), uninsured Hispanics (OR 0.27; 95% CI 0.22–0.33), and uninsured Asians (OR 0.40; 95% CI 0.22–0.73) were less likely to be discharged to rehabilitation. Race and insurance are strong predictors of discharge to rehabilitation among adult TBI survivors in the United States. Efforts are needed to understand and eliminate disparities in access to rehabilitation after TBI.
doi:10.1089/neu.2013.3091
PMCID: PMC3868359  PMID: 23972035
disparities; epidemiology; rehabilitation; traumatic brain injury
24.  The Effects of Price Competition and Reduced Subsidies for Uncompensated Care on Hospital Mortality 
Health Services Research  2005;40(4):1056-1077.
Objective
To determine whether hospital mortality rates changed in New Jersey after implementation of a law that changed hospital payment from a regulated system based on hospital cost to price competition with reduced subsidies for uncompensated care and whether changes in mortality rates were affected by hospital market conditions.
Data Sources/Study Setting
State discharge data for New Jersey and New York from 1990 to 1996.
Study Design
We used an interrupted time series design to compare risk-adjusted in-hospital mortality rates between states over time. We compared the effect sizes in markets with different levels of health maintenance organization penetration and hospital market concentration and tested the sensitivity of our results to different approaches to defining hospital markets.
Data Collection/Extraction Methods
The study sample included all patients under age 65 admitted to New Jersey or New York hospitals with stroke, hip fracture, pneumonia, pulmonary embolism, congestive heart failure, hip fracture, or acute myocardial infarction (AMI).
Principal Findings
Mortality among patients in New Jersey improved less than in New York by 0.4 percentage points among the insured (p=.07) and 0.5 percentage points among the uninsured (p=.37). There was a relative increase in mortality for patients with AMI, congestive heart failure, and stroke, especially for uninsured patients with these conditions, but not for patients with the other four conditions we studied. Less competitive hospital markets were significantly associated with a relative decrease in mortality among insured patients.
Conclusions
Market-based reforms may adversely affect mortality for some conditions but it appears the effects are not universal. Insured patients in less competitive markets fared better in the transition to price competition.
doi:10.1111/j.1475-6773.2005.00396.x
PMCID: PMC1361182  PMID: 16033492
Quality of health care; health care markets; hospital competition; mortality
25.  The Effect of Market Reform on Racial Differences in Hospital Mortality 
Journal of General Internal Medicine  2006;21(11):1198-1202.
OBJECTIVE
To determine whether racial differences in hospital mortality worsened after implementation of a New Jersey law in 1993 that reduced subsidies for uninsured hospital care and changed hospital payment from rate regulation to price competition.
DATA SOURCES/STUDY SETTING
State discharge data for New Jersey and New York from 1990 to 1996.
STUDY DESIGN
We used an interrupted time series design to compare risk-adjusted in-hospital mortality rates between states over time. Adjusting for patient characteristics, baseline interstate differences, and common intertemporal trends, we compared the effect sizes for whites and blacks in the following 4 groups: overall, uninsured, insured under age 65, and Medicare patients.
DATA COLLECTION/EXTRACTION METHODS
The study sample included 1,357,394 patients admitted to New Jersey or New York hospitals between 1990 to 1996 with stroke, hip fracture, pneumonia, pulmonary embolism, congestive heart failure, or acute myocardial infarction (AMI).
PRINCIPAL FINDINGS
The increase in mortality in New Jersey versus New York was significantly larger among blacks than among whites for AMI (2.4% points vs 0.1% points, P-value for difference .026) but not for the other 6 conditions. In groupings of conditions for which hospital admission is non-discretionary and conditions in which admission is discretionary, we found qualitatively larger increases in mortality for blacks but no statistically significant racial differences among patients overall, uninsured patients, insured patients under age 65, or Medicare patients.
CONCLUSIONS
Market-based reform and reductions in subsidies for hospital care for the uninsured in New Jersey were associated with worsening racial disparities in in-hospital mortality for AMI but not for 6 other common conditions.
doi:10.1111/j.1525-1497.2006.00484.x
PMCID: PMC1831664  PMID: 17026731
quality of health care; economics; medical; financing; organized

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