MORTALITY IN THE UNINSURED COMPARED WITH THAT IN PERSONS WITH PUBLIC AND PRIVATE HEALTH-INSURANCE

Objective: To compare mortality in persons with employer-provided heal th insurance, Medicare, Medicaid, military health benefits, other priv ate health insurance, and no health insurance, before and after adjust ment for income and employment status. Design: Cohort study using nati onal survey data containing information on social, economic, and demog raphic factors and health insurance, with deaths identified through ma tching to the National Death Index resulting in a mortality follow-up period of 5 years. Setting: Noninstitutionalized population of the Uni ted States. Participants: Approximately 150 000 respondents to nationa l surveys conducted by the US Bureau of the Census (Current Population Surveys), aged 25 to 64 years. Results: After adjustment for age and income, persons with Medicare and Medicaid had the highest mortality i n comparison with those with employer-provided insurance, with relativ e risks generally greater than 2. With adjustment for age and income, persons without insurance had higher mortality than those with employe r-provided insurance, with relative risks of 1.2 for white men and 1.5 for white women. These relationships held after adjustment for employ ment status, with the working uninsured showing mortality between 1.2 and 1.3 times higher than that of the working insured. Mortality was h igher in those with lower incomes after adjustment for insurance statu s. Those with annual income of $10 000 or less per year had mortality about two times that of persons with incomes greater than $25 000 per year. Conclusion: Mortality was lowest in employed persons with employ er-provided health insurance. The higher mortality in those with publi c insurance or with no insurance reflects an indeterminate mix of sele ction on existing health status and access to medical care.