Uninsurance Among Nonelderly Adults With and Without Frequent Mental and Physical Distress in the United States

The BRFSS is a state-based surveillance system, operated by state health departments in collaboration with the Centers for Disease Control and Prevention. The objective of the BRFSS is to collect uniform, state-specific data about preventive health practices and risk behaviors linked to chronic diseases, injuries, and preventable infectious diseases in the adult population (19,20). Trained interviewers collect data on a standardized questionnaire monthly from an independent probability sample of households with telephones among the noninstitutionalized U.S. adult population. The BRFSS questionnaire consists of core questions asked in all 50 states and the District of Columbia; supplemental modules containing a series of questions about specific topics, such as adult asthma history, intimate partner violence, and mental health; and state-added questions. All BRFSS questionnaires, data, and reports are available at www.cdc.gov/brfss.

Beginning in 1993, questions about mentally and physically unhealthy days were included in the BRFSS. These measures are widely used in state health reports and annual reports of state-level health status and mental health indicators (21). They are useful for identifying unmet health needs and disparities among demographic and socioeconomic subpopulations, characterizing the symptom burden of disabilities and chronic diseases, and tracking population patterns and trends (21). Unlike physical and mental health screening questionnaires that attempt to assess the likelihood that the respondent meets criteria for a particular mental or physical illness, the physically and mentally unhealthy days questions assess perceived level of physical and mental health.

Two questions involve respondents' self-assessment of their health over the previous 30 days. The question, “How many days was your physical health, which includes physical illness or injury, not good?” assesses physically unhealthy days. The question, “How many days was your mental health, which includes stress, depression, and problems with emotions, not good?” assesses mentally unhealthy days. These questions have demonstrated validity and reliability for population health surveillance (21–23). For example, adults with serious psychological distress report five times as many mentally unhealthy days as those without serious psychological distress (24).

We categorized mentally and physically unhealthy days as indicating either infrequent distress (zero to 13 days) or frequent distress (14 to 30 days). To be included in the analysis, persons must have responded to both questions about physically and mentally unhealthy days. Responses were further categorized into four mutually exclusive groups—those with neither frequent mental nor physical distress, those with frequent mental distress only, those with frequent physical distress only, and those with both frequent mental and physical distress. These categories were later collapsed into two categories, frequent mental distress and no frequent mental distress, on the basis of the uninsurance patterns observed in the data.

We categorized health care coverage using yes or no responses to the question, “Do you have any kind of health care coverage, including health insurance, prepaid plans such as health maintenance organizations, or Medicare or other government plan?” Covariates of interest included sex, age group (18–34 and 35–64), race or ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other), and education (less than high school, high school graduate, and at least some college education). We limited data analyses to those aged 18 to 64 years because those aged 65 years or older were generally covered by Medicare.

Data, including information about insurance status and physically and mentally unhealthy days, were available for 2,815,246 respondents aged 18 to 64 years. Data were available for all states in all years except in 2002, when data were available for only 22 states. Unadjusted prevalence estimates were calculated to examine uninsurance—that is, lack of health care coverage—over time by sociodemographic characteristic and state to provide background about the population being examined. Logistic regression models were created to examine adjusted prevalence estimates (predicted marginals) of uninsurance over time by mutually exclusive category of frequent physical and mental distress status adjusted for sex, age, race or ethnicity, and educational status. Further analyses examined the adjusted prevalence estimates of uninsurance over four time periods by frequent mental distress status, individual sociodemographic characteristic, and individual state. SUDAAN software was used for all analyses to account for BRFSS's complex survey design.

This research contained several noteworthy findings. First, even after adjustment for sociodemographic characteristics, uninsurance among adults aged 18 to 64 years was markedly higher among those with frequent mental distress only and those with both frequent mental distress and frequent physical distress than among those with frequent physical distress only. Second, the prevalence of uninsurance did not differ markedly between those with only frequent mental distress and those with both frequent mental distress and frequent physical distress, suggesting that frequent mental distress may be the driving factor in the prevalence of uninsurance in this population. Finally, the prevalence of uninsurance among those with frequent mental distress only and those with neither frequent mental distress nor frequent physical distress increased significantly over time.

Sociodemographic characteristics play a critical role in one's ability to obtain insurance (25). Uninsured adults have less access to recommended care, receive poorer quality of care, and experience worse health outcomes than insured adults (9). In this study, among those with frequent mental distress, 40% of adults with less than a high school education and more than 25% of minority populations (more than 25% of non-Hispanic blacks and 35% of Hispanics) were uninsured. According to the National Survey on Drug Use and Health, 79% of uninsured adults with mental illness or substance abuse who reported that they needed treatment indicated that they could not obtain it because of cost (26). Moreover, many persons with mental illness report incomes 200% below the federal poverty level (FPL) (27). Among persons 100% to 200% below the FPL who have mental illness or substance use disorders, approximately one-third lack public or private insurance (26).

Populations with expectations of high health care costs—such as those with chronic physical or mental illnesses—are more likely to attempt to purchase insurance than those with low risk, such as young healthy adults. However, insurance companies are more likely to deny coverage to these high-risk populations (28). Persons with mental illness are disproportionately denied insurance because of preexisting conditions (11) and according to our study the gap in coverage between those with and without mental distress is increasing over time. Our research indicated that even after adjustment for sociodemographic characteristics, the prevalence of uninsurance among those with frequent mental distress only and both frequent mental distress and frequent physical distress was significantly higher than among those with frequent physical distress only. Moreover, our results indicated that healthy young adults, persons without frequent mental or physical distress, increasingly have chosen to opt out of buying health insurance.

Our study had several limitations. First, the BRFSS may underestimate the burden of physical and mental distress because it excludes those without land-line telephones and those unable to answer the phone because of impaired physical or mental health. Second, BRFSS is based on self-reported data, and biases in reporting health insurance coverage and number of physically and mentally unhealthy days in the past 30 days may have occurred. Third, because BRFSS data about physical and mental distress for 2002 were available for only 22 states, the results for that year may not be representative of the entire country. Finally, because BRFSS data are cross-sectional, whether the lack of health insurance coverage affected or resulted from physical distress, mental distress, or both is uncertain. In other words, persons with frequent physical or mental distress or both may not seek health insurance coverage or may be denied insurance because of a preexisting condition, or people who cannot afford insurance may be more likely to subsequently develop frequent distress.

Given the disproportionately high rate of uninsurance among nonelderly adults with frequent mental distress, it will be important to monitor potential changes in health care access, utilization, and self-reported health after implementation of the ACA, particularly among those with mental illness.

The authors report no competing interests.