Schoen C, DesRoches C
The Commonwealth Fund, New York, NY 10021, USA.
Health Serv Res. 2000 Apr;35(1 Pt 2):187-206.
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).
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.
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.
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.
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.
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.
通过比较近期有过未参保时段的参保成年人、当前未参保成年人以及在参考时间段内从未有过未参保情况（持续参保）的成年人在获得医疗服务方面的经历和成本体验，来检验持续参保对于获得医疗服务的重要性。
18 - 64岁成年人。数据取自三个不同的调查数据库：罗伯特·伍德·约翰逊基金会1996 - 1997年社区追踪调查、凯撒/联邦1997年全国医疗保险调查以及1995 - 1997年凯撒/联邦州低收入调查。
该研究根据受访者在参考时间段内的保险覆盖情况报告，将个体分为三类保险组：持续参保；调查时参保但近期有过未参保时段；当前未参保。在凯撒/联邦的两项调查中，近期未参保组包括过去两年内有过未参保时段的任何参保受访者。在社区追踪调查中，近期未参保组包括过去一年内有过未参保时段的任何参保受访者。获得医疗服务的衡量指标包括在需要时放弃医疗保健、通常的医疗服务来源、医疗服务的使用、支付医疗费用的困难以及对医疗服务的满意度。
所有三项调查主要通过电话进行。社区追踪调查选取了60个社区站点，并额外抽取了全国随机样本。凯撒/联邦全国调查是全国随机样本；凯撒/联邦州低收入调查涵盖了明尼苏达、俄勒冈、田纳西、佛罗里达、得克萨斯、纽约和加利福尼亚七个州中收入处于或低于贫困线250%的18 - 64岁成年人。
与持续参保者相比，那些参保但近期有过未参保时段的人面临着得不到所需医疗服务以及支付医疗账单困难的高风险。该组报告获得医疗服务问题的可能性是持续参保者的两到三倍。近期有过未参保时段的参保成年人报告的获得医疗服务和成本问题发生率接近调查时未参保者报告的水平。这两组对所接受医疗服务的评价也比持续参保的成年人更负面。总体而言，由于区分了近期有过未参保时段的参保成年人和从未有过未参保时段的参保成年人，参保者与未参保者之间的获得医疗服务差距扩大了。
仅关注当前保险状况的研究将低估一年内有过未参保时段对获得医疗服务困难和损害医疗服务质量的影响程度，也将低估因未参保而面临风险的人口比例。需要进行政策改革以维持持续的保险覆盖并避免出现未参保时段。当前未参保和保险不稳定的成年人都面临高风险。
