In general, 40-year-old respondents perceived themselves to be in good physical and mental health, with mean values above 50 on SF-12 PCS and MCS scales.
Continuous health insurance coverage across the preceding 9-11 years was not
Probst et al. / Health Insurance Coverage and Perceived Health at Age 40 471
associated with better self-perceived physical health at age 40 in multivariable analy-sis. This finding parallels results achieved by previous researchers looking at adult populations (Kasper et al., 2000; Schoen & DesRoches, 2000). Receipt of public insurance was closely tied to reported physical health, with lower self-reported health among persons with more years of public coverage. Because participation in Medicaid, the principal source of public insurance for persons in their 30s, is closely tied to health status as well as to income, this relationship was not unexpected.
Previous work with the NLSY79 sample demonstrated that public insurance, per se, is not detrimental to eventual health status (Quesnel-Vallee, 2004).
Failure of the present research to document a relationship between continuous coverage and physical health, even with receipt of public insurance held constant, may have multiple causes. First, all respondents, even those who lacked health insur-ance, may have received all needed health care. Uninsured persons may rely on char-ity or other discounted sources of care (Johnson & Crystal, 2000). This appears unlikely, as research suggests that individuals reduce their use of care when health insurance is lost or discontinuous (Sudano & Baker, 2003). Second, individuals may fail to assess their own health accurately. However, self-rated health status has been linked to both mortality and health services utilization (Dorr et al., 2006; DeSalvo et al., 2005), suggesting that personal perceptions have reasonable validity. Perhaps most likely, respondents in their 30s may be less susceptible to the effects of fore-gone health care than older populations.
The principal influence on perceived health status at age 40, after receipt of public insurance, was health during the respondent’s 20s. Individuals reporting health limitations on their ability to work at the beginning of their adult careers demonstrated persistent poor physical health. Individuals who were smokers in their mid-20 also reported poorer health at age 40. Whether interventions at younger ages aimed at improving health or changing smoking behavior could have improved health at age 40 cannot be determined.
Poverty during the decade when respondents were in their 20s was not linked to health at age 40, after receipt of public insurance was held constant. Poverty during those years was linked to receipt of public insurance when they were in their 30s. It is likely that the association of prior poverty with subsequent public insurance flows from continued poverty; respondents were more likely to remain in poverty than to enter it. Additional research is needed to clarify both the factors associated with receipt of public insurance and the interrelationship between public insurance and health status.
The long-term effects of family history found in our analysis was striking. Even with multiple present and past factors held constant, individuals whose parents had low education levels reported worse physical health than their counterparts. Health habits and attitudes formed during youth may persist. An emerging literature sug-gests that mortality is affected by childhood social status, in addition to adult status (Beebe-Dimmer et al., 2004; Pensola & Martikainen, 2004; Poulton et al., 2002),
and by financial status at midlife as well as financial status in later life (Hayward &
Gorman, 2004). In addition, research is beginning to link childhood experiences with adult morbidity (Blackwell, Hayward, & Crimmins, 2001).
Effects of Health Insurance on Mental Health
Continuous insurance coverage was not associated with better self-perceived men-tal health scores. Principal factors affecting MCS included sex, immutable in Andersen’s (1995) model, baseline mental health as measured by the Rosenberg Self-Esteem Scale, and the experience of poor health during 1979-1988. Elements of the Rosenberg Self-Esteem Scale parallel questions about self-worth used in screening for depression (Beck, Steer, & Garbin, 1988). Thus, self-perceived mental health at age 40 may be a continuation of mental states experienced in 1980. Research has found that many persons testing positive for mental health disorders on screening instruments do not seek care. In 1990, for example, at about the midpoint of the 20 years covered by the present research, only about one fifth of persons with a poten-tial mental health disorder sought treatment from any health professional for this problem (Kessler et al., 1994). Links between prior poor physical health and lower perceived mental health may be related to the persistence of poor health over time.
Prior research has found that both concurrent poor physical health and changing physical health status are associated with depression (e.g., Egede & Zheng, 2003). As noted in the preceding section, the degree to which interventions can reduce the occurrence of health limitations that interfere with work remains to be explored.
The relationship between marijuana or hashish use at the beginning of adulthood and mental health scores is intriguing, given the current high prevalence of these behaviors and the potential for intervention. High school students tapped by the Youth Risk Behavioral Survey (YRBS) constitute the population most similar to the NLSY cohort that is currently examined on a regular basis. The 2005 YRBS found that 22.8% of high school seniors had used marijuana within the past 30 days, and 47.6% reported lifetime use (Centers for Disease Control and Prevention, 2006). Continued research is needed to delineate the population of youth engaged in these behaviors and to devise interven-tions which reduce use or serve to mitigate its consequences.
Limitations
Limitations to the present study involve the measurement of insurance coverage, the age of respondents, and the use of self-report measures. The analysis is based on the percentage of time insured between 1989 and 1998/2000, but does not distin-guish between persons whose period of uninsurance was early in the study period and those for whom it might have been recent, or between a single extended period of uninsurance and multiple such periods. However, the definition of “continuous coverage” is fairly straightforward, and the time span covered is greater than that
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used by most previous research. Second, age 40 is relatively young for detecting the health effects of undiagnosed or untreated disease. Even persons with diagnosed but asymptomatic medical problems, such as hypertension, may not “feel bad.” Third, all health outcomes were based on respondent self-report, although validated instru-ments were used. The most likely result of using self-report data is that the true preva-lence of disease in the population is underestimated, again biasing the study conservatively. Finally, it should be noted that the models, while significant, do not explain a large part of the variance in PCS (multiple R2= .1565) or MCS (multiple R2 = .0798).
Conclusion
A substantial subset (40.3%) of a nationally representative cohort of adults lacked continuous health insurance coverage in the years before they reached age 40.
Among African Americans and Hispanics, nearly three of every five persons experi-enced gaps in coverage, reflecting previous work which suggests that gaps in cover-age disproportionately affect minorities (Hargraves, 2004) and low wcover-age workers (Collins, Davis, Doty, & Ho, 2004). Absent policy change, insurance premiums are projected to increase over the next 10 years, further exacerbating gaps in coverage (Gilmer & Kronick, 2005; Long & Shen, 2004). Intermittent coverage with antici-pated adverse effects on continuity of care and management of chronic disease will be a typical experience for a substantial group of American adults.
The present research did not find that lack of continuous health insurance cover-age was associated with poorer self-rated physical or mental health. However, research suggests that the NLSY79 adults, now in their early 40s, will continue to be at risk for gaps in health insurance coverage as they grow older (Baker & Sudano, 2005), if current levels of insurance in the population do not change. Among persons in their 50s, lack of insurance and intermittent coverage has been associated with adverse health outcomes (Baker, Feinglass, et al., 2006; Baker, Sudano, et al. 2001, 2002; Dor et al., 2006).
The present policy atmosphere is volatile. On one hand, insurance products focusing on demand management have grown, as payors seek to restrain insurance costs. Consumer-driven health plans and other refinements to the present system of employer-sponsored insurance are being marketed to employers (Gabel, Whitmore, Rice, & Lo Sasso, 2004) and proposed by state Medicaid agencies (Sanford, 2005).
In the private sector, the number of consumer-driven plans is increasing despite employers’ reservations regarding their long-term efficacy (Gabel et al., 2004). Work examining medical savings accounts, a predecessor of the current consumer-driven offerings, found that they were principally used by persons at the upper end of the income spectrum and thus would not be likely to benefit all workers (Minicozzi, 2006). Our findings suggest that such plans, with their emphasis on reducing first dollar spending, will not have immediately perceived effects on physical health
among employees of age 40 or younger. Effects among persons above age 40, or among persons with longstanding chronic disease, may be markedly different, as indicated by research among older working-age populations (Baker, Sudano, et al., 2001, 2002) and by findings from the Health Insurance Experiment of the late 1970s (Davis, 2004).
Recent actions at the state level suggest the emergence of an alternative policy direction focusing on universal coverage (Davis, 2007). While universal coverage legislation passed in Massachusetts and proposed in California, has garnered the most coverage in the popular press, 17 additional states are exploring legislation or have legislative initiatives under way to expand health insurance access (National Conference of State Legislatures, n.d.). The Massachusetts program combines a requirement that individuals be insured with subsidies for low income persons and fees assessed on business that do not offer insurance to workers (Kaiser Commission, 2006; Rowland, 2006). Whether these and other initiatives will emerge as a viable solution for extending the possible benefits of financial access to care uni-formly across the population remains to be seen.
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