Journal of General Internal Medicine

, Volume 22, Issue 4, pp 502–507

Risk of Cardiovascular Events and Death—Does Insurance Matter?

  • Angela Fowler-Brown
  • Giselle Corbie-Smith
  • Joanne Garrett
  • Nicole Lurie
Original Article

DOI: 10.1007/s11606-007-0127-2

Cite this article as:
Fowler-Brown, A., Corbie-Smith, G., Garrett, J. et al. J GEN INTERN MED (2007) 22: 502. doi:10.1007/s11606-007-0127-2



Many Americans lack health insurance. Despite good evidence that lack of insurance compromises access to care, few prospective studies examine its relationship to health outcomes.


To determine the relationship between insurance and cardiovascular outcomes and the relationship between insurance and selected process measures.


We used data from 15,792 participants in the Atherosclerosis Risk in Communities Study, a prospective cohort study. Participants were enrolled in 1987–1989 and returned for follow-up visits every 3 years, for a total of 4 visits.


We estimated the hazard of myocardial infarction, stroke, and death associated with insurance status using Cox proportional hazard modeling. We used generalized estimating equations to examine the association between insurance status and risk of (1) reporting no routine physical examinations, (2) being unaware of a personal cardiovascular risk condition, and (3) inadequate control of cardiovascular risk conditions.


Persons without insurance had higher rates of stroke (adjusted hazard ratio, 95% CI 1.22–2.22) and death (adjusted hazard ratio 1.26, 95% CI 1.03–1.53), but not myocardial infarction, than those who were insured. The uninsured were less likely to report routine physical examinations (adjusted risk ratio 1.13, 95% CI 1.08–1.18); more likely to be unaware of hypertension (adjusted risk ratio 1.12, 95% CI 1.00–1.25) and hyperlipidemia (adjusted risk ratio 1.11, 95% CI 1.03–1.19); and more likely to have poor blood pressure control (adjusted risk ratio 1.23, 95% CI 1.08–1.39).


Lack of health insurance is associated with increased rates of stroke and death and with less awareness and control of cardiovascular risk conditions. Health insurance may improve cardiovascular risk factor awareness, control and outcomes.


insurancecerebrovascular diseasecardiovascular diseasepopulations at riskmortalityatherosclerosis

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Angela Fowler-Brown
    • 1
    • 2
  • Giselle Corbie-Smith
    • 1
    • 2
    • 3
  • Joanne Garrett
    • 4
  • Nicole Lurie
    • 5
  1. 1.Division of General Medicine and EpidemiologyUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillUSA
  3. 3.Department of Social MedicineUniversity of North Carolina at Chapel HillChapel HillUSA
  4. 4.Center for Women’s Health ResearchUniversity of North Carolina at Chapel HillChapel HillUSA
  5. 5.RAND CorporationArlingtonUSA
  6. 6.Division of General Medicine and Primary CareBeth Israel Deaconess Medical CenterBrooklineUSA