Baker David W, Sudano Joseph J, Durazo-Arvizu Ramon, Feinglass Joseph, Witt Whitney P, Thompson Jason
Department of Medicine and the Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
Med Care. 2006 Mar;44(3):277-82. doi: 10.1097/01.mlr.0000199696.41480.45.
Although individuals' health insurance coverage changes frequently, previous analyses have not accounted for changes in insurance coverage over time.
We sought to determine the independent association between lack of insurance and the risk of a decline in self-reported overall health and death from 1992 to 2002, accounting for changes in self-reported overall health and insurance coverage.
We analyzed data from the Health and Retirement study, a prospective cohort study of a national sample of community-dwelling adults age 51-61 years old at baseline. Major decline in self-reported overall health and mortality was determined at 2-year intervals.
People who were uninsured at baseline had a 35% (95% confidence interval [CI] 12-62%) higher risk-adjusted mortality from 1992 to 2002 compared with those with private insurance. However, when we analyzed outcomes over 2-year intervals, individuals who were uninsured at the start of each interval were more likely to have a major decline in their overall health (pooled adjusted relative risk 1.43, 95% CI 1.28-1.63), but they were equally likely to die (pooled adjusted relative risk 0.96, 95% CI 0.73-1.27). Of the 1512 people who were uninsured at baseline, 220 (14.6%) died; of those who died, only 70 (31.8%) were still uninsured at the HRS interview prior to death.
Death does not appear to be a short-term consequence of being uninsured. Instead, higher long-term mortality among the uninsured results from erosion in this population's health status over time and the attendant higher mortality associated with this. Most deaths among the uninsured occur after individuals have gained either public or private health insurance.
尽管个人的医疗保险覆盖情况经常变化，但以往的分析并未考虑到保险覆盖情况随时间的变化。
我们试图确定1992年至2002年间未参保与自我报告的总体健康状况下降及死亡风险之间的独立关联，同时考虑自我报告的总体健康状况和保险覆盖情况的变化。
我们分析了健康与退休研究的数据，该研究是一项对基线时年龄在51 - 61岁的全国社区居住成年人样本进行的前瞻性队列研究。每两年确定一次自我报告的总体健康状况和死亡率的重大下降情况。
与拥有私人保险的人相比，基线时未参保的人在1992年至2002年间经风险调整后的死亡率高出35%（95%置信区间[CI] 12 - 62%）。然而，当我们按两年间隔分析结果时，每个间隔开始时未参保的个体更有可能出现总体健康状况的重大下降（合并调整相对风险1.43，95% CI 1.28 - 1.63），但他们死亡的可能性相同（合并调整相对风险0.96，95% CI 0.73 - 1.27）。在基线时未参保的1512人中，220人（14.6%）死亡；在这些死亡者中，只有70人（31.8%）在死亡前的健康与退休研究访谈时仍未参保。
死亡似乎不是未参保的短期后果。相反，未参保者中较高的长期死亡率源于该人群健康状况随时间的恶化以及随之而来的较高死亡率。未参保者中的大多数死亡发生在个体获得公共或私人医疗保险之后。
