Chronic illnesses more often undiscovered, undertreated in uninsured

By Elizabeth Cooney
Boston Globe
October 20, 2009

Uninsured people are also more likely to have undiagnosed and undertreated medical conditions, according to a new study comparing chronic illnesses among Americans with and without health coverage. The results offer possible clues to a recently reported higher death rate among people who lack insurance.

Researchers from Cambridge Health Alliance and Boston Medical Center tracked diabetes, high blood pressure, and high cholesterol in a national survey of more than 15,000 working-age adults. Based on questionnaires, medical exams, and lab test results, they found that about half of uninsured people who had diabetes or high cholesterol were unaware of it, compared with just under one-quarter of insured people who did not know they had these conditions. High blood pressure, however, was undiagnosed in about a quarter of both uninsured and insured people.

Once diagnosed, hypertension was poorly controlled in 58 percent of uninsured people and 51 percent of those with insurance. The treatment gap was larger for high cholesterol: 77 percent of uninsured versus 60 percent of insured people had inadequately treated levels.

For diabetes control, the difference in treatment was not as clear. Insurance status did not matter in achieving good diabetes control, as defined by the national survey conducted by the US Centers for Disease Control and Prevention. But using less stringent measures that the authors say are more commonly used by physicians, 31 percent of uninsured diabetics were in poor control of their blood sugar levels, compared with 25 percent of insured diabetics.

"The diagnosis and control of chronic illness is substandard even in people with insurance," Dr. Steffie Woolhandler, co-author of the article appearing online today in Health Affairs, said in an interview. "But it's much, much worse for the uninsured."

Woolhandler said the study results fit with research published last month linking 45,000 deaths each year to the lack of insurance. The same group wrote both articles.

"We know that you can prevent deaths through good treatments for high blood pressure, for diabetes, and for high cholesterol," she said. "These common conditions are easily treated, but if you don't treat them, they can turn lethal."

Chronic conditions are diagnosed and treated through regular doctors' visits and medication regimens, both of which can be out of reach for the uninsured, Woolhandler said.

The study's conclusions are not surprising, according to Lindsey Tucker, Health Reform Policy Manager for the advocacy group Health Care For All.

"This paper demonstrates yet again the importance of having and retaining health insurance," she said in an e-mail interview. "As we know from our policy work as well as from our HelpLine callers, uninsurance is costly not only for the individual but also for the state and the health care system."