Insured Patients More Likely to Be Diagnosed, Treated

Empirical analysis confirms that insured people are more likely to be diagnosed and treated for high blood pressure, diabetes, and high cholesterol, a researcher says.

People with health insurance are more likely than uninsured people to have chronic conditions diagnosed and under a treatment regimen, according to estimates by researchers at Harvard T.H. Chan School of Public Health.

The study, appearing this month in Health Affairs, uses 10-years of Patient Protection and Affordable Care Act insurance enrollment projections from the Congressional Budget Office to estimate the number of people who might benefit from improved diagnoses and treatment of high blood pressure, diabetes, and high cholesterol.  

"I was surprised that the effect was consistent and detectable across all three of these conditions," says Joshua Salomon, lead author of the study and a professor of global health at Harvard. "In each case, insurance improved diagnoses; in each case insurance improved control, and if you look at the clinical outcomes, in each case the outcomes were healthier for those who had insurance."

Salomon estimated that if the number of nonelderly Americans without health insurance were reduced by half, as the CBO projects, there would be 1.5 million newly insured individuals diagnosed with one or more of these conditions, and 659,000 newly insured individuals able to achieve control of at least one condition.

Salomon conceded that the findings that insured people are more likely to be diagnosed and treated could have been predicted.

"It's because of the lack of direct evidence in general that we were surprised at the degree to which the different measures we looked at all told a consistent story of the benefit from insurance. That was the hypothesis we were testing, but we were surprised by the consistency of the results," he says.

"As healthcare professionals, this is certainly what we would have hoped to find, but there has been surprisingly little empirical analysis of this question in part because it is hard to answer."

"We tend to look for experimental studies to believe cause and effect and there are a few of those. To my frustration, a lot of the discourse around the ACA and health reform in general focuses on cost almost to the exclusion of the health impact. So, the results are intuitive. Perhaps it is surprising that we are able to see effects on health outcomes, not just diagnoses."

The Harvard researchers analyzed data from 28,157 people ages 20 to 64 participating in the National Center for Health Statistics' National Health and Nutrition Examination Survey (NHANES) from 1999 to 2012. The researchers found that insured people had a significantly higher probability of being diagnosed with a chronic disease than similar people without insurance—by 14 percentage points for diabetes and high cholesterol, and 9 percentage points for high blood pressure.

Among those already diagnosed, having insurance was associated with higher probabilities of achieving standard clinical benchmarks for control of each condition, and with significantly healthier average levels of blood sugar, total cholesterol, and systolic blood pressure.

Salomon says his study is not particularly concerned about measuring the return-on-investment or cost savings that comes with the expansion of health insurance.

"I think it's the wrong benchmark. Not everything has to be cost saving to be good value for the money," he says. "We tend to look for cost savings when in fact we are willing to spend money on health and some of our money can be spent in a way that buys health in a relatively inexpensive way and some money can be spend buying health in a more costly way."

"I would say the benchmark should be whether an intervention policy saves money and improves health. That is a higher bar to reach. There are very few examples of interventions that have shown cost savings and health improving. But we should be looking to see if our policies produce health at a cost that represents good value."