Study Finds that Those Who Decline Employer-Sponsored Coverage Are In Worse Health Than Employees Who Take Up Coverage

People who turn down employer-sponsored coverage are generally in worse health than those who participate in employer plans, according to a study in the latest issue of Health Affairs. In an effort to gain a broader understanding of "uninsured decliners" and their health status, Linda Blumberg, a senior research associate at the Urban Institute, and Len Nichols, formerly a principal research associate at the institute and now the vice president of the Center for Studying Health System Change, analyzed data from the 1997 National Health Interview Survey, which includes responses from 39,832 households. Some of the results from the study, which featured responses from 7,831 decliners of employer-sponsored insurance, 22,346 with employer-based coverage, or "takers," and 13,628 uninsured people who were not offered employer coverage, or "uninsured not offered," are provided below:

• Thirty-five percent of uninsured decliners said their health status was excellent, compared to 39.8% of takers and 32.1% of uninsured not offered. For the most part, the health status of decliners was statistically insignificant from the uninsured not offered.
• Uninsured decliners were more likely than takers to have spent more than seven days in bed in the past 12 months and to have stayed home from work more frequently, a combination that "impl[ies] that uninsured decliners were more likely to be sick than takers were, and they may be more likely to be seriously ill when sick."
• Decliners were more likely to go longer periods of time without seeing a health care provider.
• The "most startling" difference between the two groups was found in mental health conditions, as 13.7% of decliners and 13.8% of uninsured not offered said they were depressed in the past 30 days, compared to 7.6% of takers.
• The study found that a similar percentage from all three groups -- around 18% -- said that their health status was better compared to a year ago. But a greater percentage of decliners and uninsured not offered said they were worse off than takers. Further, more people in the latter two groups also said they couldn't afford drugs, mental health services and dental care in the past year.

A 'Fundamental' Decision
Blumberg and Nichols write that the results of the study "are somewhat surprising, for we expected workers voluntarily declining coverage to be healthier than those enrolling." They conclude that the lesser health status of decliners "does not change the fundamental calculus: To these workers, the marginal value of insurance is lower than the out-of-pocket cost they would face if they were to become insured." The authors state that, while decliners should also be considered, government policies should primarily target workers who do not have access to employer-sponsored coverage, because they make up the "bulk of the working uninsured" and their "health status is practically identical to that of uninsured decliners ... and those without offers are even less likely to have seen a doctor lately, to have a usual source of care" and to have received preventive care. They conclude: "What are the health consequences of being uninsured for a long time, and are decliners unaware of them? The answers to these questions will have important ramifications for policy and for efforts to educate workers about the value of health insurance coverage" (Blumberg/Nichols, "The Health Status of Workers Who Decline Employer-Sponsored Insurance," November/December 2001).