Health Care Equally Poor for Everyone, Studies Show

Published May 1, 2006

Two new studies–one from the New England Journal of Medicine (NEJM) and the other by the U.S. Census Bureau–compare the effects of health insurance on health status and on the proportion of “recommended” care individuals receive when they visit their doctor.

A RAND study, published in the March 16 edition of the NEJM, found all Americans tend to receive similar proportions of the care “recommended” for their conditions once they set foot in their physician’s office. The study did not measure results for those who fail to seek care.

This finding is surprising, considering that widespread health disparities are thought to exist among ethnic groups within the population. Psychiatrist Sally Satel, an American Enterprise Institute scholar and author of the January 2006 book, The Health Disparities Myth, found the RAND study intriguing.

“It showed no meaningful differences in primary care procedures among individuals with access to care, irrespective of sex, race, insurance type–including none–and geographic location,” Satel said, adding, “what was significant was the inadequate rate at which all patients received these interventions.”

Uniformly Poor Care

The study found the population as a whole receives a little more than half of the care medical experts agree should be given for various diseases and chronic conditions. Additionally, it found the type of health coverage people possess doesn’t seem to matter: Those without health insurance receive only about 53.7 percent of recommended care; individuals with private (non-managed care) coverage get 53.6 percent. Medicaid enrollees receive about 54.9 percent of recommended care, while those in managed care get about 55.2 percent.

Similarly, lack of education is often thought to create barriers to receiving appropriate care. However, individuals who do not finish high school receive 54.6 percent of recommended care, while those with a college or graduate degree receive only slightly more, at 55.7 percent.

Surprisingly, income also didn’t have much bearing on whether a person receives needed care. Individuals in households earning more than $50,000 were only 3.5 percent more likely to receive recommended care than those earning less than $15,000 (56.6 percent versus 53.1 percent).

Gender Gaps

Steven Asch, lead author of the RAND study, maintains that merely going to the doctor isn’t always enough.

“We found once patients get in the door they are likely to experience another set of barriers to receiving needed care,” Asch said in a March 15 news release accompanying the study.

The biggest variation between groups is gender. Overall, men receive 52.3 percent of recommended care, while women receive 56.6 percent. Men are less likely than women to receive recommended chronic care (55 percent versus 58 percent). The gap for preventive services is greater (50 percent for men versus 58 percent for women). This finding is somewhat counterintuitive, considering men are slightly more apt to list their health as “excellent” or “very good” (67 percent) compared to women (64 percent).

Income Barriers

The second report, published in February by the U.S. Census Bureau, looked at insurance coverage, health status, and use of medical services. It found lack of health coverage doesn’t appear to reduce health status: Only about 3 percent of the uninsured complained of being in “poor” health (an additional 9 percent claimed their health status was only “fair”). At the other end of the spectrum, 32 percent of the uninsured said their health status was “excellent.”

In all, 87.9 percent of the uninsured considered their health to be “excellent,” “very good,” or “good”–almost the same proportion as those with health coverage (88.1 percent).

Of uninsured people living in poverty, health status was only slightly worse. Just 4.7 percent claimed they were in “poor” health, while 84 percent listed their health as “excellent,” “very good,” or “good.”

Neither do the uninsured appear to be shunning their doctors’ offices: 21 percent have visited a doctor or dentist while uninsured. As would be expected, health care provider visits increase as health status declines. Only 12 percent of those in excellent health visited a doctor or dentist, whereas 63.2 percent of those in poor health had done so in 2001, when the study was conducted. Those figures are nearly identical for low-income people without health coverage. (The Census report did find some differences in physician visits among ethnic groups.)

Health Insurance Myths

Some of the findings from both these studies are at odds with longstanding beliefs that health care is synonymous with health insurance, and that health insurance is a precursor for good health and quality health care. An earlier RAND study, published in the journal Health Affairs in 1994, showed the uninsured receive only half to two-thirds as much care as individuals covered by health insurance.

Public health advocates have long argued that since uninsured individuals receive less medical care, they must also miss out on necessary medical services. However, the new RAND study found that once patients enter their physicians’ office, care is equally limited regardless of the type of health coverage.

“The results of our study will be surprising to some people,” RAND coauthor Elizabeth McGlynn said in the statement, “but the findings make it clear that the quality problem affects all of us.”

Public health researchers will probably debate the meaning of these two studies for years to come. Satel said focusing only on disparities is misguided.

“With regard to primary care, at least,” Satel said, “fixating on group differences is a distraction from the larger problem of improved care for all.”

Devon Herrick, Ph.D. ([email protected]) is a health economist and senior fellow at the National Center for Policy Analysis in Dallas.

For more information …

Steven M. Asch, et al., “Who is at Greatest Risk for Receiving Poor-Quality Health Care?” New England Journal of Medicine, Vol. 354, No. 11, March 16, 2006, pp. 1147-1156, is available online at

Shailesh Bhandari, “Health Status, Health Insurance, and Health Services Utilization: 2001,” Current Population Reports, Publication P70-106, U.S. Census Bureau, February 2006, is available online at