Universal Health Insurance: Not a Cure-All

Reform may offer less benefit to minorities and the poor

Minorities and the poor — the largest group of uninsured Americans — suffer disproportionately from health problems. But would guaranteed coverage make everything better?

The short answer: No.

According to a little-noticed finding in a recent Institute of Medicine report: “Health insurance by itself will not eliminate ethnic and socioeconomic disparities in health.” [2]The conclusion is based on a University of California at San Francisco analysis of research spanning 16 years.

“While health insurance may alleviate financial barriers to care and improve the choice of providers,” the analysis said, “it does not address other individual and societal determinants of poor health experienced by ethnic minorities and the disadvantaged.” [3]

In short, the authors cautioned, the United States “should not be content to focus only on insurance [to correct] social disparities in health.” Scandinavia, Japan and the United Kingdom, for example, have failed to erase socioeconomic differences despite their well-established systems of universal health coverage. [4]

Less affluent persons might use a free health system more often, but that hardly guarantees the health outcomes enjoyed by the better off. For instance, a study of death rates among English civil servants — all covered by health insurance — determined that unskilled laborers and clerical staff had the greatest risk of dying within 10 years, while professionals and top administrators could be expected to live longer. [5]

In the United States, many assume that disadvantaged minorities would substantially benefit from equal access to medical practitioners, prevention and treatment. After all, racial and ethnic minorities with incomes below the federal poverty level represent a substantial proportion of the uninsured. Hispanics are three times more likely than whites to lack health insurance, and African-Americans twice as likely. [6]Indeed, some researchers suggest that racial and ethnic differences in health are due mostly to differences in socioeconomic status. [7]

Yet the University of California team showed that better care frequently failed to improve the health of minorities, the poor or the lesser educated. A study of 5,986 men, women and children with one of 17 chronic illnesses, all receiving free care or sharing in the cost, found that the poor were less likely to receive “appropriate” care than their better-off counterparts. [8]

Other studies suggest that the rates of receiving hospitalization and preventive care from health professionals depend not solely on whether people have insurance but also on race and ethnicity. Insurance also could narrow but not close the substantial gaps between the races in mortality — whites live an average six years longer than non-whites. Even when adjusting for differences in income, one-third of the difference in the mortality rate remains. [9]

Several factors tend to offset the potentially positive impact of free insurance on a person’s health, including low literacy skills, which make it harder to either understand a doctor’s instructions or choose between treatments. A person’s health beliefs, lifestyle practices and environmental influences can also affect his health. [10]People who are less educated may be less capable of communicating with a doctor, understand possible risks, appreciate the significance of symptoms, schedule an appointment or manage their conditions. [11]

The prejudices of medical professionals, cross-cultural communication failures and overt discrimination also may play a role, experts say. Other studies suggest an association between poor health and crowded neighborhoods, exposure to stressful life events and the inability to take time off from work to see a doctor.

Said Harold Freeman, president of the Ralph Lauren Cancer Center at New York City’s North General Hospital and for three decades a surgeon in Harlem: “Giving everyone an insurance card won’t solve health disparities.” [12]

[2] Committee on the Consequences of Uninsurance, Institute of Medicine, “Care Without Coverage: Too Little, Too Late,” May 2002. Copies also available athttp://www.nap.edu/.

[3] Jennifer S. Haas and Nancy E. Adler, “The Causes of Vulnerability: Disentangling the Effects of Race, Socioeconomic Status and Insurance Coverage on Health,” Institute of Medicine, October 2001.

[4] A.E. Kunst and J.P. Machenbach, “The Size of Mortality Differences Associated with Educational Level in Nine Industrialized Countries,” American Journal of Public Health, June 1994, pp. 932-937.

[5] M.G. Marmot, M.J. Shipley and G. Rose, “Inequalities in Death: Specific Explanations of a General Pattern?” Lancet, May 1984, pp. 1003-1006.

[6] Institute of Medicine, “Coverage Matters: Insurance and Health Care,” 2001. See also J. Rhodes and M. Chu, “Health Insurance Status of the Civilian Non-Institutionalized Population: 1999,” Agency for Healthcare Research and Policy, 2000.

[7] Paul D. Sorlie et al., “Mortality in the Uninsured Compared with that in Persons with Public and Private Health Insurance,” Archives of Internal Medicine, November 1994, pp. 2409-2416.

[8] The study, known as the “Rand Health Insurance Experiment,” is by R.H. Brook et al.., “Quality of Ambulatory Care: Epidemiology and Comparison by Insurance Status and Income,” Medical Care, May 1990, pp. 392-433.

[9] Jan E. Mutchler and Jeffrey A. Burr, “Racial Differences in Health and Health Care Service Utilization in Later Life: The Effect of Socioeconomic Status,” Journal of Health and Social Behavior, December 1991, pp. 342-356.

[10] Haas and Adler, op. cit., p. 26.

[11] S.K. Behera and Marilyn Winkleby, “Low Awareness of Cardiovascular Disease Risk Among Low-Income African-American Women,” American Journal of Health Promotion, May/June 2000, pp. 301-305.

[12] Quoted in Gabriele Amersbach, “Through the Lens of Race: Unequal Health Care in America,” Harvard Public Health Review, winter 2002.