The Annals of Internal Medicine Tells Us About the Burden of Chronic Illness Among the Uninsured (and it's not pretty)

The Aug 5th issue of the Annals of Internal Medicine has an interesting article by Wilper et al from Harvard titled ‘A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults.’ The authors drilled into six years’ worth of National Health and Nutrition Examination Survey (‘NHANES’) data involving individuals between 18 and 64. Since NHANES is representative of the U.S. population, the authors were able to extrapolate the data and obtain a snapshot of the health status of the 36 million Americans in this age group who don’t have health insurance.

Their findings indicate that about one third or 11 million of these individuals have at least one chronic condition. They include cardiovascular disease (1.3 million), hypertension (5.9 million), diabetes (1.4 million), hypercholesterolemia (4 million), lung disease (3.5 million) or previous cancer (1.1 million). 23% of these persons have not seen a physician in the last year and 26% were unable to identify a particular health clinic that they rely on.

The Disease Management Care Blog’s only criticism of the study is that it’s not clear that ‘hypercholesterolemia’ is such an awful disease, since high lipids, in the absence of other risk factors, doesn’t usually warrant ‘treatment.’

Yet, this was an eye-opening study. Until this publication came alone, the DMCB underestimated the prevalence of chronic illness among the uninsured. It also needs to rethink the uninsureds’ reputation of being healthy and well-off enough to ‘risk’ going without health insurance. Last but not least, the reassurance of the ‘non-collapsing’ health care system safety-net apparently means little to the over two million uninsured persons with a chronic condition who are not making an appointment to see a doctor.

What is the solution for these millions of Americans with diabetes, high blood pressure, heart disease, lung disease and cancer in remission? The DMCB believes there merit to the notion that we need a mix of mandated participation (play or pay) plus public funding for a ‘bare necessities’ insurance product. Given the preponderance and escalating costs of chronic illness, risk pools and the individual market are not up to the task: good coverage is simply unaffordable and the death spiral will rule.

Based on Massachusetts’ experience, we are also learning that simply providing health insurance is not enough. We know that the primary care system is a key ingredient in providing cost-effective care for persons with chronic illness and that in many areas of the country, there are insufficient numbers of PCPs to meet the pent-up demand.

More on the implications of this in a future post.