The convergence of vulnerable characteristics and health insurance in the US

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Abstract

This study defines vulnerability as a multi-dimensional construct, reflected in the convergence of predisposing, enabling, and need attributes of risk. Using race, income, and self-perceived health status as indicators and based on eight rounds of the US 1996 panel of the Medical Expenditure Panel Survey, the study examined how the interactions of these vulnerable characteristics affect insurance coverage, a critical measure of health care access. The results of the study demonstrate insurance coverage does vary with the extent of vulnerability. While race and income significantly influence insurance coverage, respectively, there was relatively little disparity in insurance due to health status. Between race and income, income was a more significant predictor of lack of insurance coverage since low-income people regardless of race and health were significantly more likely to be uninsured or partially insured. However, it is important to note that minorities were disproportionately over-represented in the low-income or bad health groups so that any adverse association between income, bad health, and insurance status would affect minorities significantly more than whites. Among those with insurance, the most vulnerable group, the minority-low-income-bad health group or those with all the three vulnerability indicators, were most likely to be publicly insured. A policy implication is to target limited resources on insurance coverage for the more vulnerable groups, those with a convergence or cluster of predisposing, enabling, and need attributes of risk.

Section snippets

Defining vulnerability

From a health perspective, vulnerability refers to the likelihood of experiencing poor health and is determined by a convergence of predisposing, enabling, and need characteristics at both individual and ecological levels. Poor health can be manifested physically, psychologically, and/or socially. Since poor health along one dimension is likely to be compounded by poor health along others, the health needs are greater for those with problems along multiple dimensions than those with problems

Data

Data for this study came from the household component (HC) of the 1996 panel of the medical expenditure panel survey (MEPS), a nationally representative survey of the US civilian non-institutionalized population cosponsored by the agency for healthcare research and quality (AHRQ) and the National Center for Health Statistics (NCHS). Since several of the policy-relevant vulnerable population sub-groups were oversampled including Hispanics and blacks, those with functional problems, and

Results

Table 1 displays the sample and population distributions of insurance coverage by vulnerability measured as the convergence of race, income, and self-perceived health status. Note, due to the exclusion of those with Medicare (an entitlement program for those over 65) and missing values as a result of coding, the sample of 19,116 individuals can be generalized to over 236 million or over 87% of US population. First of all, it is important to note that minorities were more likely to be classified

Discussion

This study defines vulnerability as a multi-dimensional construct, reflected in the convergence of predisposing, enabling, and need attributes of risk. This broad definition of vulnerability presumes that vulnerable populations are those that experience risks in clusters and that those susceptible to multiple risks (e.g., being of racial/ethnic minority, children, and poor) are likely to be more vulnerable than those susceptible to single risk (e.g., high-income minority or children of high

Acknowledgements

We thank Wei Hua and Xiao Hu for the excellent computer programming assistance in producing the analyses. Comments and suggestions from the editor and three anonymous reviewers are greatly appreciated.

References (38)

  • L.A. Aday

    At risk in AmericaThe health and health care needs of vulnerable populations in the United States

    (1993)
  • L.A. Aday

    Indicators and predictors of health services utilization

  • L.A. Aday

    Health status of vulnerable populations

    Annual Review Public Health

    (1994)
  • L.A. Aday

    Vulnerable populationsA community-oriented perspective

  • R.J. Angel et al.

    The extent of private and public health insurance coverage among adult Hispanics

    The Gerontologists

    (1996)
  • Anonymous. (1997). Health insurance: Coverage leads to increased health care access for children. (Publication no....
  • D. Blumenthal et al.

    The efficacy of primary care for vulnerable population groups

    Health Services Research

    (1995)
  • Cohen, J., (1997a). Design and methods of the medical expenditure panel survey household component. MEPS Methodology...
  • Cohen, J., (1997b). Sample design of the medical expenditure panel survey household component. MEPS Methodology Report...
  • Council on Ethical and Judicial Affairs of the American Medical Association. (1990). Black–white disparities in health...
  • Council on Scientific Affairs of the American Medical Association. (1991). Hispanic health in the United States. JAMA,...
  • G.J. Demko et al.

    Populations at Risk in AmericaVulnerable groups at the end of the twentieth century

    (1995)
  • M.M. Farmer et al.

    Distress and perceived healthMechanisms of health decline

    Journal of Health and Social Behaviour

    (1997)
  • E.L. Idler et al.

    Self-rated health and mortalityA review of twenty-seven community studies

    Journal of Health and Social Behaviour

    (1997)
  • E.L. Idler et al.

    Self-ratings of healthDo they also predict change in functional ability?

    Journal of Gerontology B Psychological Science and Social Science

    (1995)
  • B.P. Kennedy et al.

    Income distribution, socioeconomic status, and self-rated health in the United Statesmultilevel analysis

    British Medical Journal

    (1998)
  • M.D. Kogan et al.

    The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States

    Journal of American Medical Association

    (1995)
  • .E Kramarow et al.

    Health, United States, 1999

    (1999)
  • N. Lurie

    Studying access to care in managed care environment

    Health Services Research

    (1997)
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