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STATISTICAL BRIEF #260:
Attitudes toward Health Insurance and Their Persistence over Time, Adults 2006-2007

September 2009

Steven B. Cohen, PhD

Highlights

In 2007, 11.2 percent of adults agreed with the statement "I'm healthy enough that I really don't need health insurance," and 24.9 percent of adults agreed with the statement "Health insurance is not worth the money it costs."
There were no differences in the overall national estimates when comparing the 2007 attitudes towards health insurance with those observed in 2006; however, substantial shifts in preferences were noted for the same individuals over this time period.
Adults ages 18-64 who were uninsured for all of 2007 were at least twice as likely as their insured counterparts to indicate they were healthy and did not need health insurance. These uninsured adults were also more likely to agree that health insurance was not worth its cost, relative to those with coverage.
Adults with consistent attitudes toward health insurance in both 2006 and 2007 had coverage and utilization behaviors in accordance with their expressed preferences. Those who consistently said they were healthy and did not need coverage were at least two and one half times as likely not to have any ambulatory or inpatient visits in both years, relative to those who consistently disagreed with that classification.
In both years, adults under age 65 who consistently indicated that health insurance was not worth the cost were nearly three times as likely to be uninsured relative to those who consistently disagreed.

Introduction

Health insurance helps individuals receive timely access to medical care and protects them against the risk of expensive and unanticipated medical events. In addition to the socioeconomic profiles that distinguish individuals with coverage from those who are uninsured, attitudes regarding the need for and value of health insurance coverage may also affect coverage decisions. Given the potential for individuals' health care preferences to influence health behaviors, it is important to measure the population's attitudes towards health insurance coverage and to examine the persistence of these attitudes over time.

The Household Component of the Medical Expenditure Panel Survey (MEPS-HC) contains a series of self-administered questions that discern individual attitudes regarding the need for health insurance coverage and its cost. Adults age 18 and over are asked whether they strongly agree, agree, are uncertain, disagree, or strongly disagree with each of the following statements: "I'm healthy enough that I really don't need health insurance" and "Health insurance is not worth the money it costs."

This Statistical Brief provides a summary of the attitudes adults have regarding the need for health insurance coverage and its cost over the time period 2006-2007, based on data from the 2006 and 2007 MEPS-HC. A description of the variation in agreement levels with these attitudes for adults further distinguished by demographic and socioeconomic characteristics is also provided. In addition, the persistence in these attitudes toward health insurance coverage is examined. For this report, strongly agreed and agreed responses were combined into an "agreed" category while strongly disagreed and disagreed responses were combined into a "disagreed" category. All differences between estimates discussed in the text are statistically significant at the 0.05 level unless otherwise noted.

Findings

In 2007, 11.2 percent of adults age 18 and over (25 million people, estimate not shown) who were members of the U.S. civilian noninstitutionalized population agreed with the statement "I'm healthy enough that I really don't need health insurance," while another 81.9 percent disagreed, and 6.9 percent expressed uncertainty (figure 1). When restricted to the adult population under age 65, 12.2 percent agreed with the statement (data not shown). Furthermore, no differences in the 2007 national estimates for this health care preference measure were observed, relative to the corresponding attitudinal profiles that characterized the nation in 2006.

When focused on attitudes related to the cost of health insurance coverage, 24.9 percent of adults age 18 and over in 2007 (56 million people, estimate not shown) agreed with the statement "Health insurance is not worth the money it costs," another 62.4 percent disagreed, while 12.7 percent expressed uncertainty (figure 1). When restricted to the adult population under age 65, 26.7 percent agreed with the statement (data not shown). Again, no differences in national estimates for this health care preference measure were observed, relative to the corresponding attitudinal profiles that characterized the nation in 2006.

While the national estimates of these attitudinal items were relatively stable between 2006 and 2007, an examination of the persistence in attitudes over the two-year period revealed a substantial shift in preferences within individuals over time (figure 2). This assessment of the persistence in attitudes over time was restricted to adults who were in the U.S. civilian noninstitutionalized population for both years. With respect to the statement "I'm healthy enough that I really don't need health insurance," only 4.7 percent of individuals agreed with the statement in both years. In addition, 70.9 percent disagreed in both years. The remainder was characterized by a change in attitude over time or uncertainty in response. With respect to the statement "Health insurance is not worth the money it costs," only 11.8 percent of individuals agreed with the statement in both years. Similarly, only 45.6 percent disagreed in both years. The remaining individuals were characterized by a change in attitude over time or uncertainty in response.

In 2007, adults below the age of 45 were more likely than older individuals to indicate that they are healthy and do not need health insurance (figure 3) and to feel that health insurance was not worth the cost (figure 4). In comparisons by race/ethnicity, Hispanics were more likely than white non-Hispanics and black non-Hispanics to indicate they were healthy and not in need of coverage (17.5 percent versus 10.1 percent and 9.6 percent, respectively; figure 3) and that insurance was not worth the cost (27.5 percent versus 24.8 and 22.9 percent, respectively; figure 4). In addition, adult males were more likely than females to indicate that they are healthy and do not need health insurance (14.2 percent versus 8.4 percent, figure 3) and to feel that health insurance was not worth the cost (27.6 percent versus 22.4 percent, figure 4).

In 2007, adults with fewer than 12 years of education were more likely than individuals with 13 or more years of education to indicate they were healthy and not in need of coverage (13.3 percent versus 10.3 percent, respectively; figure 3). In addition, adults who were classified as high income in the prior year, were less likely than their counterparts with lower incomes to indicate they were healthy and not in need of coverage (figure 3) and to feel that health insurance was not worth the cost (figure 4). Furthermore, adults between the ages of 18 and 64 who were uninsured for all of 2007 were approximately twice as likely as their insured counterparts to agree with the statement "I'm healthy enough that I really don't need health insurance" (22.2 percent versus 10.2 percent and 8.5 percent for the privately and publicly insured, respectively; figure 3). These uninsured adults were also more likely to agree with the statement "Health insurance is not worth the money it costs" (37.8 percent, figure 4), relative to those with private or public coverage (24.9 percent and 22.3 percent, respectively).

For adults with consistent attitudes regarding the need for coverage based on health status in both 2006 and 2007, those indicating they were healthy and did not need coverage were about two and one half times as likely not to have any ambulatory visits or inpatient stays expense (46.7 percent, 2006; 47.0 percent, 2007; figure 5), relative to those who disagreed in both years (18.0 percent, 2006; 18.7 percent, 2007; figure 5). They were also substantially less likely to indicate they were in fair or poor health status (3.3 percent, 2006; 3.5 percent, 2007; figure 5), relative to those who disagreed (15.6 percent, 2006; 15.2 percent, 2007; figure 5). Furthermore, adults under the age of 65 who consistently indicated they were healthy and not in need of coverage were nearly three times as likely to be uninsured for an entire year (34.7 percent, 2006; 36.3 percent, 2007; figure 5), relative to those who disagreed (12.5 percent, 2006; 12.8 percent, 2007; figure 5).

For adults with consistent attitudes regarding the cost of health insurance in both 2006 and 2007, those indicating health insurance was not worth the cost were approximately twice as likely not to have any ambulatory visits or inpatient stays expense (31.5 percent, 2006; 32.3 percent, 2007; figure 6), relative to those who disagreed in both years (17.3 percent, 2006; 17.6 percent, 2007; figure 6). Furthermore, adults under the age of 65 who consistently indicated that health insurance was not worth the cost were substantially more likely to be uninsured for an entire year (26.6 percent, 2006; 28.2 percent, 2007; figure 6), relative to those who disagreed (9.2 percent, 2006; 9.3 percent, 2007; figure 6).

Data Source

The estimates shown in this Statistical Brief are drawn from analyses conducted by the MEPS staff from the following public use files: 2006 Full Year Population Characteristics, HC-099, the 2007 Full Year Population Characteristics, HC-107. The level of item nonresponse associated with the attitude questions from the 2006 and 2007 SAQ (self-administered questionnaire) instruments was approximately 2 percent.

Definitions

Longitudinal classifications of attitudinal responses
Individuals with responses of agree or strongly agree to the attitudinal items in both years were classified as "agree both years." Individuals with responses of disagree or strongly disagree to the attitudinal items in both years were classified as "disagree both years." Individuals with responses of disagree, strongly disagree, or uncertain in 2006 and with responses of agree or strongly agree to the attitudinal items in 2007 were classified as "shift to agree." Individuals with responses of agree, strongly agree, or uncertain in 2006 and with responses of disagree or strongly disagree to the attitudinal items in 2007 were classified as "shift to disagree." All other responses were classified as "other uncertain." The longitudinal analyses were conditioned on responses to the SAQ in 2006 and 2007 for the same individuals with MEPS Panel 11 longitudinal weights. Over 88 percent of these longitudinal respondents in MEPS also responded to the SAQ in both years.

Uninsured
Individuals classified as uninsured throughout the year did not have public only or private health insurance coverage during that time interval. Individuals covered only by noncomprehensive State-specific programs (e.g., Maryland Kidney Disease Program) or private single-service plans (e.g., coverage for dental or vision care only, coverage for accidents or specific diseases) were considered to be uninsured.

Public only coverage
Individuals were considered to have public only health insurance coverage if they were not covered by private insurance and they were covered by Medicare, Medicaid, TRICARE, or other public only hospital and physician coverage.

Private coverage
Private health insurance coverage was defined as nonpublic insurance that provided coverage for hospital and physician care (including Medigap coverage).

Race/ethnicity
Classification by race/ethnicity was based on information reported for each family member. Respondents were asked if each family member's race was best described as American Indian, Alaska Native, Asian or Pacific Islander, black, white, or other. They also were asked if each family member's main national origin or ancestry was Puerto Rican; Cuban; Mexican, Mexicano, Mexican American, or Chicano; other Latin American; or other Spanish. All persons whose main national origin or ancestry was reported in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. Since the Hispanic grouping can include black Hispanic, white Hispanic, Asian and Pacific Islanders Hispanic, and other Hispanic, the race categories of black, white, Asian and Pacific Islanders, and other do not include Hispanics. MEPS respondents who reported other single or multiple races and were non-Hispanic were included in the other category. For this analysis, the following classification by race and ethnicity was used: Hispanic (of any race), non-Hispanic blacks single race, non-Hispanic whites single race, and non-Hispanic others.

Poverty status
Sample persons were classified according to the total yearly income of their family. Within a household, all people related by blood, marriage, or adoption were considered to be a family. Poverty status categories are defined by the ratio of family income to the Federal income thresholds, which control for family size and age of the head of family. Poverty status was based on annual income in 2006.

Poverty status categories are defined as follows:

Poor: Persons in families with income less than or equal to the poverty line, including those who had negative income.
Near poor: Persons in families with income over the poverty line through 125 percent of the poverty line.
Low income: Persons in families with income over 125 percent through 200 percent of the poverty line.
Middle income: Persons in families with income over 200 percent through 400 percent of the poverty line.
High income: Persons in families with income over 400 percent of the poverty line.

Health status
In every round, the respondent is asked to rate the health of every member of the family. The exact wording of the question is: "In general, compared to other people of (PERSON)'s age, would you say that (PERSON)'s health is excellent, very good, good, fair, or poor?" The health status classification in Rounds 2 and 4 was used for this report.

About MEPS-HC

MEPS-HC is a nationally representative longitudinal survey that collects detailed information on health care utilization and expenditures, health insurance, and health status, as well as a wide variety of social, demographic, and economic characteristics for the U.S. civilian noninstitutionalized population. It is cosponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.

For more information about MEPS, call the MEPS information coordinator at AHRQ (301-427-1656) or visit the MEPS Web site at http://www.meps.ahrq.gov/.

References

For a detailed description of the MEPS-HC survey design, sample design, and methods used to minimize sources of nonsampling error, see the following publications:

Cohen, J., Cohen S., and Banthin, J. "The Medical Expenditure Panel Survey: A National Information Resource to Support Healthcare Cost Research and Inform Policy and Practice." Medical Care 2009, 47(7), Supplement, pp S44-S50.

Cohen, J. Design and Methods of the Medical Expenditure Panel Survey Household Component. MEPS Methodology Report No. 1. AHCPR Pub. No. 97-0026. Rockville, MD: Agency for Health Care Policy and Research, 1997. http://www.meps.ahrq.gov/mepsweb/data_files/publications/mr1/mr1.shtml

Cohen, S. B. Attitudes toward Health Insurance and Their Persistence over Time, Adults 2003-2004. Statistical Brief #161. February 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st161/stat161.shtml

Cohen, S. "Design Strategies and Innovations in the Medical Expenditure Panel Survey." Medical Care, July 2003: 41(7) Supplement: III-5-III-12.

Ezzati-Rice, TM, Rohde, F, Greenblatt, J, Sample Design of the Medical Expenditure Panel Survey Household Component, 1998-2007. Methodology Report No. 22. March 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/mr22/mr22.shtml

Machlin, S. and K. Carper. Attitudes toward Health Insurance among Adults Age 18 and Over. Statistical Brief #87. July 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st87/stat87.shtml

Suggested Citation

Cohen, S. B. Attitudes toward Health Insurance and Their Persistence over Time, Adults 2006-2007. Statistical Brief #260. September 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st260/stat260.shtml

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AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Statistical Brief and other MEPS data and tools and to share suggestions on how MEPS products might be enhanced to further meet your needs. Please e-mail us at mepspd@ahrq.gov or send a letter to the address below:

Steven B. Cohen, PhD, Director
Center for Financing, Access, and Cost Trends
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850