Journal of General Internal Medicine

, Volume 22, Issue 4, pp 502–507 | Cite as

Risk of Cardiovascular Events and Death—Does Insurance Matter?

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

Abstract

BACKGROUND

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.

OBJECTIVE

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

DESIGN AND PARTICIPANTS

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.

MAIN OUTCOME MEASURES

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.

RESULTS

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).

CONCLUSIONS

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.

KEY WORDS

insurance cerebrovascular disease cardiovascular disease populations at risk mortality atherosclerosis 

References

  1. 1.
    DeNavas-Walt C, Proctor BD, Lee CH. Current Population Reports, Income Poverty and Health Insurance Coverage in the United States: 2005. Washington, D.C.: U.S. Census Bureau, U.S. Government Printing Office. 2006;60–231.Google Scholar
  2. 2.
    Franks P, Clancy CM, Gold MR. Health insurance and mortality. Evidence from a national cohort. JAMA. 1993;270(6):737–41.PubMedCrossRefGoogle Scholar
  3. 3.
    Sorlie PD, Johnson NJ, Backlund E, Bradham DD. Mortality in the uninsured compared with that in persons with public and private health insurance. Arch Intern Med. 1994;154(21):2409–16.PubMedCrossRefGoogle Scholar
  4. 4.
    Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284(16):2061–9.PubMedCrossRefGoogle Scholar
  5. 5.
    The ARIC investigators. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives. Am J Epidemiol. 1989;129(4):687–702.Google Scholar
  6. 6.
    Schoenfeld D. Partial residuals for the proportional hazards regression model. Biometrika. 1982;69:239–41.CrossRefGoogle Scholar
  7. 7.
    McNutt LA, Wu C, Xue X, Hafner JP. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol. 2003;157(10):940–3.PubMedCrossRefGoogle Scholar
  8. 8.
    Brook RH, Ware JE Jr., Rogers WH, Keeler EB, Davies AR, Donald CA, et al. Does free care improve adults’ health? Results from a randomized controlled trial. N Engl J Med. 1983;309(23):1426–34.PubMedCrossRefGoogle Scholar
  9. 9.
    Keeler EB, Brook RH, Goldberg GA, Kamberg CJ, Newhouse JP. How free care reduced hypertension in the health insurance experiment. JAMA. 1985;254(14):1926–31.PubMedCrossRefGoogle Scholar
  10. 10.
    Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-Cal—does it affect health? N Engl J Med. 1984;311(7):480–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH. Termination of Medi-Cal benefits. A follow-up study one year later. N Engl J Med. 1986;314(19):1266–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Fihn SD, Wicher JB. Withdrawing routine outpatient medical services: effects on access and health. J Gen Intern Med. 1988;3(4):356–62.PubMedCrossRefGoogle Scholar
  13. 13.
    Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke. N Engl J Med. 1995;333(21):1392–400.PubMedCrossRefGoogle Scholar

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

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