Hafner-Eaton C
RAND/UCLA Center for Health Policy Study.
JAMA. 1993 Feb 10;269(6):787-92.
This study examines the associations between lack of health insurance coverage and physician utilization for the chronically ill, acutely ill, and well nonelderly populations in the United States.
Cross-sectional data from the 1989 National Health Interview Survey, conducted by the National Center for Health Statistics, were analyzed for the nonelderly population using a correlational, two-group design (N = 102,055). Analytic models, using multiple logistic regression, were tested to predict the odds and likelihood of physician utilization for the uninsured and insured in the three subpopulations (ie, chronically ill, acutely ill, and well), controlling for health status, number of conditions, and geographic, sociodemographic, and economic factors. Disparities in utilization were then calculated between the uninsured and insured for each subpopulation.
The nonelderly uninsured were consistently less likely than the insured to have received any health care within 12 months. Moreover, there were differential effects of being uninsured on utilization depending on whether an individual was chronically ill, acutely ill, or well. Whereas chronically ill and well uninsured persons were half as likely to have seen a physician as their insured counterparts (odds ratio, 0.50), acutely ill uninsured persons were almost two thirds as likely to receive physician care (odds ratio, 0.62). Thus, the disparity in physician utilization between the uninsured and insured was larger for the chronically ill and well than for the acutely ill; uninsured acutely ill were less likely to go without care. Of the three populations, those in the well population had average disparities with the largest magnitude (40%), compared with disparities of the chronically ill (20%) and acutely ill (10%).
These disparities represent large inequities in utilization of care by the uninsured, particularly for the chronically ill and well. Whether these disparities result from lower access or individual choice cannot be determined from this study. When viewed in light of other studies examining the impact of utilization on health status, these results provide support for the development of comprehensive health insurance packages with universal coverage and better inclusion of chronic and preventive care models in benefit packages.
本研究调查了美国未参保人群与慢性病患者、急性病患者以及健康非老年人群在就医方面的关联。
利用美国国家卫生统计中心开展的1989年国民健康访谈调查的横断面数据，采用相关性两组设计对非老年人群进行分析（N = 102,055）。运用多元逻辑回归分析模型，预测三个亚组人群（即慢性病患者、急性病患者和健康人群）中未参保者和参保者就医的几率和可能性，并对健康状况、疾病数量以及地理、社会人口统计学和经济因素进行控制。然后计算每个亚组中未参保者和参保者在就医方面的差异。
非老年未参保者在12个月内接受任何医疗保健服务的可能性始终低于参保者。此外，未参保对就医的影响因个体是慢性病患者、急性病患者还是健康人群而有所不同。慢性病患者和健康未参保者看医生的可能性仅为参保者的一半（比值比，0.50），而急性病未参保者接受医生治疗的可能性几乎为参保者的三分之二（比值比，0.62）。因此，未参保者和参保者在就医方面的差异在慢性病患者和健康人群中比在急性病患者中更大；急性病未参保者不太可能得不到治疗。在这三个人群中，健康人群的平均差异幅度最大（40%），而慢性病患者的差异为20%，急性病患者的差异为10%。
这些差异表明未参保者在医疗服务利用方面存在巨大不平等，尤其是慢性病患者和健康人群。本研究无法确定这些差异是由于就医机会较少还是个人选择所致。结合其他研究对医疗服务利用对健康状况影响的考察，这些结果为制定全面的医疗保险套餐提供了支持，该套餐应具有普遍覆盖性，并在福利套餐中更好地纳入慢性和预防保健模式。
