Chronic diseases and their management have become a primary focus for the health system, due to an apparently growing prevalence and the fact that they account for much of our health spending. Two studies in Health Affairs look at true prevalence of these conditions and whether the insurance expansion under the reform law will lead to more diagnoses and treatment of them. (HA Article) (HA Article) In the first article, researchers looked at trends for three conditions–diabetes, high blood pressure and high blood lipid levels. They determine that determining prevalence solely by treatment understates the true prevalence, largely due to people failing to pay regular visits to the doctor. At the same time treated prevalence is growing much faster than treated prevalence, giving rise to a false perception of the overall prevalence increase for the diseases. Treated diabetes prevalence is about 8% of the population, true prevalence is estimated at 12.5%; treated hypertension is estimated at 26%, true prevalence at 33%; high lipids at 28% treated prevalence and 35.6% true prevalence. True diabetes prevalence grew from 7.5% in 2000 to 12.5% in 2012, high lipids basically stayed flat and hypertension rose from 27% to 33% in this time period.
In the second study, using national survey data, the authors determined that people with insurance were 14% more likely to have a diagnosis of diabetes or of hyperlipidemia and 9% more likely to have a hypertension diagnosis. This suggests that as tens of millions of people gain coverage under the reform law, there will be many more diagnoses of these diseases, with resulting treatment. The researchers adjusted the analysis to account for the possibility that people with more health problems might be more likely to seek insurance than healthy persons.
The relationship between insurance, health and total health spending is complex. It certainly appears to be true, and accords with common sense, that having insurance means people probably will see clinicians more often and will have more diseases and conditions diagnosed and treated. So we might expect their health spending to go up. If we followed these individuals for a long enough time, or even for their entire life, would they be in better health than if they didn’t have insurance, and, separately, would they have less total long-term or lifetime health spending. The answer to these questions is very murky and there are not good studies that I am aware of. It does not appear to be axiomatic that having insurance equals better health status. Other than feeling less financial stress related to the cost of insurance (which isn’t getting lower anymore for commercial insureds with high premium cost-shares, high copays and high deductibles, unlike gold-plated coverage given to Medicaid recipients), the research does not support the idea that health is better just because of insurance. And long-term spending may not be less either, since if insurance did result in people being in better health, they usually would live longer and eventually get an expensive disease, as they would have a few years earlier without the insurance. So I don’t buy the idea that health insurance will lower total long-term health spending. That doesn’t mean health insurance isn’t important if it does ensure that people more of the care they really need and end up in better health, regardless of the long term health spending consequences. That better health for each person should be the real objective of our health system.