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Risk of Cardiovascular Events and Death—Does Insurance Matter?

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.

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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.

    PubMed  Article  CAS  Google 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.

    PubMed  Article  CAS  Google 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.

    PubMed  Article  CAS  Google 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.

    Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  CAS  Article  Google 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.

    PubMed  Article  CAS  Google 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.

    PubMed  CAS  Article  Google 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.

    PubMed  CAS  Article  Google 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.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke. N Engl J Med. 1995;333(21):1392–400.

    PubMed  Article  CAS  Google Scholar 

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Acknowledgements

This work was supported by grants from the U.S. Department of Health and Human Services, Health Resources and Services Administration [T32-HP14001]; the National Heart Lung Blood Institute at the National Institutes of Health; and the Robert Wood Johnson Harold Amos Medical Faculty Development Program and was previously presented in abstract form at the national meetings of the Society for General Internal Medicine (2004) and of the AcademyHealth (2004). The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute contracts N01-HC-55015, N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, N01-HC-55021, and N01-HC-55022. The National Heart, Lung, and Blood Institute approved a draft of the manuscript. Angela Fowler-Brown had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors thank the staff and participants of the ARIC study for their important contributions. We also pay tribute to the contributions of Dr. Paul McGovern, who helped conceptualize this study before his untimely death.

Potential Financial Conflicts of Interest

None disclosed.

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Correspondence to Angela Fowler-Brown MD, MPH.

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Fowler-Brown, A., Corbie-Smith, G., Garrett, J. et al. Risk of Cardiovascular Events and Death—Does Insurance Matter?. J GEN INTERN MED 22, 502–507 (2007). https://doi.org/10.1007/s11606-007-0127-2

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KEY WORDS

  • insurance
  • cerebrovascular disease
  • cardiovascular disease
  • populations at risk
  • mortality
  • atherosclerosis