Age- and State-Specific Prevalence Estimates of Insured and Uninsured Persons -- United States, 1995-1996

Lack of health insurance has been associated with delayed health care (1) and increased mortality (2). Underinsurance (i.e., the inability to pay out-of-pocket expenses despite having insurance) also may result in adverse health consequences (3). Insurance coverage varies with age and locality (4), but state-specific estimates of insurance status by age are not regularly published. To characterize insurance coverage status by age, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1995-1996. Because persons aged 55-64 years are not yet eligible for Medicare, may be in fair or poor health, risk eroding retirement savings if they incur major medical expenses, and must pay high individual health premiums (5), characteristics of uninsured persons aged 55-64 years also were examined. This report summarizes the results of the analysis and indicates that a substantial proportion of all adults are either uninsured or underinsured.

The BRFSS is a continuous, state-based, random-digit-dialed telephone survey of persons aged greater than or equal to 18 years in the United States (6). For this report, data collected during 1995 and 1996 were combined to decrease variance in estimates. The study included 186,493 respondents aged 18-64 years who responded to insurance questions; of these, 26,238 were aged 55-64 years. Estimates were statistically weighted by sex, age, and race/ethnicity to reflect the noninstitutionalized civilian population of each state. Standard errors were calculated taking into account the complex survey design. Prevalence estimates were reported only when the standard error was less than 30% of the estimate; as a result, state-specific rates for underinsured persons are not presented. Respondents were categorized as uninsured if they answered "no" to the question "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?" Respondents were categorized as underinsured if they answered "yes" to the preceding question and to the question "Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?" (7). Adequate insurance was defined as reporting both being insured and having no access problems because of cost.

Overall, 16.3% of respondents were uninsured, 6.8% were underinsured, and 76.9% were adequately insured. Being uninsured was most frequently reported by persons aged 18-24 years (median for all states: 25.4%; range: 11.6%-39.9%) (Table_1); being underinsured, by persons aged 25-34 years (median: 7.5%; range: 4.6%-11.2%) and 35-44 years (median: 7.2%; range: 3.3%-11.1%); and being adequately insured, by persons aged 55-64 years (median: 84.4%; range: 71.7%-93.4%). Hawaii had the lowest prevalence of being uninsured for two of five age groups. Louisiana had the highest levels of being uninsured among three age groups, and Texas had the highest levels among two age groups.

Among persons aged 55-64 years, 5.2% (Maryland and Michigan) to 21.4% (Louisiana) were uninsured, and approximately 1.9% to 11.3% were underinsured. Although 35% of persons aged 55-64 years resided in the South, 45% of the uninsured and 44% of the underinsured in this age group resided in the South. * Women comprise 53% of persons aged 55-64 years and 56% of the uninsured in this age group. Although widowed and separated women were 1.3 times more likely to be uninsured than men of similar marital status, most (53%) uninsured women were married. Blacks and Hispanics represented 9% and 6%, respectively, of persons aged 55-64 years and 15% each of uninsured persons in this age group. Blacks and Hispanics aged 55-64 years reported higher mean rates of being uninsured than did whites; the uninsured rate for blacks in this age group ranged from 1.3 to 2.6 times the rate for whites in the West and Midwest, respectively; for Hispanics the uninsured rate ranged from 2.3 to 3.4 times the rate for whites in the Northeast and West, respectively. Among persons aged 55-64 years, 40% of uninsured persons and 30% of underinsured persons reported an annual household income of less than $15,000.

In a separate analysis, BRFSS estimates for uninsured persons were compared with those from the 1995 National Health Interview Survey (NHIS) Health Insurance supplement (8). For this supplement, insurance status was determined by responses to a series of questions about specific types of insurance plans, including private, public, military, Indian Health Service, or single-purpose plans. Respondents with any of these types of insurance plans were categorized as insured. A total of 54,495 respondents aged 18-64 years were included for analysis; 7288 were aged 55-64 years.

Between the two data sources, no statistically significant differences in national prevalence were observed for uninsured persons. However, the NHIS prevalence estimate for persons aged 55-64 years (9.3% **) was lower than the BRFSS estimate (11.0%). By region, NHIS estimates of being uninsured were slightly lower than BRFSS means for persons aged 55-64 years; differences ranged from 0.1% in the Northeast to 2.6% in the South.

Reported by the following BRFSS coordinators: J Cook, MBA, Alabama; P Owen, Alaska; B Bender, MBA, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; D McTague, MS, Florida; K Powell, MD, Georgia; A Onaka, PhD, Hawaii; A James, Idaho; B Steiner, MS, Illinois; K Horvath, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Jiles, PhD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; F Ramsey, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; L Powers, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; C Roe, MS, Vermont; L Redman, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; C Mitchell, Washington, DC; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. Health Care and Aging Studies Br and Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report are consistent with previous studies that have documented that persons aged 18-24 years had the highest rates of being uninsured and that persons aged 55-64 years had the highest rates of being insured (4). State variation in insurance coverage has been reported (4,7) and may be related to differences in employment-based health coverage (4). The regional and state variation found among persons aged 55-64 years has not been reported.

The findings in this report indicate that a substantial proportion of all adults, including those aged 55-64 years, are either uninsured or underinsured, placing these persons at increased risk for unnecessary morbidity or mortality (1-3). Approaches to increase coverage for these populations include more affordable private insurance, a national health insurance program, or allowing certain segments of the population to purchase Medicare. Although the purchase of Medicare coverage might appeal to many uninsured persons, particularly those aged 55-64 years, those with household incomes less than $15,000 would probably be unable to purchase Medicare coverage without assistance.

The findings in this report are subject to at least three limitations. First, because these results are based on self-reported telephone survey data, the number of uninsured persons is a conservative estimate and the findings are subject to reporting biases. Second, differences observed between NHIS and BRFSS regional estimates of the percentage of persons aged 55-64 years who are uninsured probably reflect methodologic differences. Finally, when combined for 1995-1996, BRFSS data provided stable state estimates of insurance status; however, similar information at a local level is not available and would be useful for policy development and health planning.

References

1. Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991;114:325-31.

2. Franks P, Clancy CM, Gold MR. Health insurance and mortality: evidence from a national cohort. JAMA 1993;270:737-41.

3. Blendon RJ, Donelan K, Hill CA, Carter W, Beatrice D, Altman D. Paying medical bills in the United States: why health insurance isn't enough. JAMA 1994;271:949-51.

4. Snider SC. Who are the medically uninsured in the United States? Stat Bull Metrop Insur Co 1994;75:20-30.

5. Davis K. Uninsured in an era of managed care. Health Serv Res 1997;31:641-9.

6. CDC. Health risks in America: gaining insight from the Behavioral Risk Factor Surveillance System. Revised edition. Atlanta: US Department of Health and Human Services, CDC, 1997.

7. CDC. State-specific prevalence estimates of uninsured and underinsured persons -- Behavioral Risk Factor Surveillance System, 1995. MMWR 1998;47:51-5.

8. Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1995. Hyattsville, Maryland: US Department of Health and Human Services, CDC, National Center for Health Statistics. (Vital and health statistics, series 10, no. 199) (in press).

* Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

TABLE 1. Percentage of persons aged 18-64 years who were uninsured, by state and
age group -- United States,  Behavioral Risk Factor Surveillance System, 1995-1996
=========================================================================================
                   18-24 years   25-34 years   35-44 years   45-54 years    55-64 years
                   -----------   -----------   -----------   -----------    -----------
State                 %    SE*      %     SE      %     SE      %     SE       %     SE
---------------------------------------------------------------------------------------
Alabama            24.1    2.5   22.7    1.7   15.5    1.3   12.0    1.4    13.6    1.7
Alaska             33.3    4.3   18.6    1.9   19.0    2.0   11.0    1.6    18.9    4.0
Arizona            31.3    3.1   22.1    2.3   19.3    2.2   14.0    1.9     9.8    1.7
Arkansas           28.2    3.0   20.7    1.8   20.8    1.6   16.7    1.7    15.6    1.7
California         38.7    2.3   26.3    1.3   18.6    1.5   14.8    1.4    15.1    1.6
Colorado           27.0    3.1   20.2    1.7   12.8    1.2   10.4    1.3    10.6    1.7
Connecticut        21.1    3.0   14.6    1.4    9.9    1.4    5.8    0.9     6.0    1.2
Delaware           23.5    2.8   14.0    1.5   10.4    1.0    8.8    1.2    11.5    1.7
Florida            34.5    2.4   23.8    1.4   20.3    1.2   15.0    1.2    14.5    1.3
Georgia            17.0    2.2   11.3    1.1    8.3    0.8   11.6    1.3     8.8    1.6
Hawaii             11.6    1.9   10.1    1.3    8.3    1.0    5.6     +      0.9     +
Idaho              29.3    2.1   19.3    1.3   15.5    1.1   13.0    1.3    12.5    1.4
Illinois           30.0    2.2   14.8    1.2    9.7    0.9    7.4    0.9    11.3    1.5
Indiana            19.9    2.1   16.3    1.4   10.6    1.0    7.5    1.0    10.8    1.5
Iowa               20.3    1.7   15.9    1.1    8.7    0.8    6.8    0.8     7.1    1.0
Kansas             23.4    2.6   16.6    1.5    9.2    1.0    8.0    1.1     8.2    1.5
Kentucky           27.1    2.2   20.1    1.4   14.3    1.2   12.9    1.2    12.6    1.4
Louisiana          33.8    2.8   28.7    2.0   21.2    1.7   22.7    2.0    21.4    2.4
Maine              33.6    3.8   18.2    1.9   17.2    1.6   13.2    1.6    12.9    2.0
Maryland           22.5    1.9   13.0    0.9    8.7    0.8    7.8    0.8     5.2    0.7
Massachusetts      22.0    3.0   14.5    1.4   10.7    1.1    8.4    1.3     5.8    1.5
Michigan           21.3    2.0   12.1    1.1    8.6    1.0    6.4    0.9     5.2    1.0
Minnesota          14.6    1.4   10.9    0.8    7.9    0.7    5.1    0.6     5.5    0.8
Mississippi        23.9    2.9   17.3    1.8   15.8    1.6   15.5    1.8    12.5    1.8
Missouri           28.0    3.2   16.9    1.5   16.3    1.7   12.6    1.7    13.8    2.1
Montana            28.5    3.3   23.6    2.0   17.8    1.5   17.5    1.8     9.7    1.8
Nebraska           17.0    2.5   10.8    1.3    9.1    1.1    7.5    1.2     8.0    1.4
Nevada             31.6    3.5   16.9    1.8   16.7    1.7   14.1    1.8    10.5    1.8
New Hampshire      32.8    3.7   15.3    1.6    9.3    1.1    7.3    1.2    12.7    2.0
New Jersey         18.0    2.4   16.7    1.8    9.8    1.4    6.5    1.0     6.0    1.2
New Mexico         39.8    4.3   24.6    2.5   21.0    2.1   18.2    2.2    12.9    2.2
New York           27.0    2.3   18.1    1.1   12.8    1.1    8.9    1.0     7.2    1.0
North Carolina     26.5    2.3   15.8    1.2   14.2    1.1    9.0    1.0     8.8    1.2
North Dakota       20.9    2.3   17.8    1.6   10.5    1.2    9.7    1.3     8.6    1.8
Ohio               30.1    3.2   13.9    2.0   11.1    1.5    6.7    1.2     8.0    1.7
Oklahoma           30.3    3.0   23.6    1.9   19.0    1.8   14.0    1.8    17.3    1.9
Oregon             30.0    2.4   19.5    1.4   13.2    1.0    9.9    1.0     9.9    1.3
Pennsylvania       22.1    2.1   15.0    1.2   11.1    0.9    7.9    0.8     7.6    1.1
Rhode Island       20.0    2.7   17.4    1.6   10.6    1.1    8.3    1.3     7.5    1.5
South Carolina     25.3    3.3   18.4    1.7   13.2    1.3   12.9    1.5    13.7    1.9
South Dakota       19.5    2.1   15.1    1.5    9.6    1.1    7.9    1.2     7.1    1.3
Tennessee          25.6    2.3   14.3    1.3   10.4    1.1   11.2    1.2     8.5    1.4
Texas              39.9    3.3   24.3    1.7   21.5    1.6   16.6    1.7    21.3    2.5
Utah               21.2    2.1   16.1    1.3   10.5    1.1    8.5    1.1     8.2    1.3
Vermont            21.2    2.5   16.4    1.3   12.2    1.1   12.1    1.2    11.8    1.4
Virginia           24.4    2.7   15.6    1.4   11.6    1.2   12.1    1.7    12.5    2.0
West Virginia      33.4    2.7   27.8    1.7   20.1    1.4   12.9    1.3    12.6    1.4
Washington         25.1    2.0   17.7    1.2   10.8    0.1    9.2    0.9     7.6    1.0
Wisconsin          21.7    2.8   12.1    1.6    7.7    1.0    5.8    1.0     6.6    1.3
Wyoming            36.6    2.6   25.1    1.6   16.5    1.1   12.4    1.2    14.7    1.6

Median             25.4          16.9          11.9          10.1           10.5
---------------------------------------------------------------------------------------
* Standard error.
+ SE was <30% of the estimate.
=========================================================================================

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