The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults

Andrew P. Wilper, MD, MPH; Steffie Woolhandler, MD, MPH; Karen E. Lasser, MD, MPH; Danny McCormick, MD, MPH; David H. Bor, MD; and David U. Himmelstein, MD
[+] Article, Author, and Disclosure Information

From Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts.

Acknowledgment: The authors thank John Z. Ayanian, MD, and Sarah Hollopeter, MD, for their comments on an earlier draft of the manuscript, and Amy Cohen, Manager of Instructional Computing, Harvard School of Public Health, for her help with statistical software.

Grant Support: By Health Resources and Service Administration National Research Service Award 5T32 HP110011 (Dr. Wilper).

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol: The NHANES methodology is available from the Centers for Disease Control and Prevention (http://www.cdc.gov/nchs/about/major/nhanes/datalink.htm.) Statistical code and data set: Available from Dr. Wilper (e-mail, awilper@hsph.harvard.edu).

Requests for Single Reprints: Andrew P. Wilper, MD, Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02139; e-mail, awilper@hsph.harvard.edu.

Current Author Addresses: Drs. Wilper, Woolhandler, Lasser, McCormick, Bor, and Himmelstein: Cambridge Health Alliance/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02144.

Author Contributions: Conception and design: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, D.U. Himmelstein.

Analysis and interpretation of the data: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.U. Himmelstein.

Drafting of the article: A.P. Wilper, S. Woolhandler.

Critical revision of the article for important intellectual content: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, D.U. Himmelstein.

Final approval of the article: A.P. Wilper, S. Woolhandler, K.E. Lasser, D. McCormick, D.H. Bor, D.U. Himmelstein.

Statistical expertise: A.P. Wilper, S. Woolhandler, D.U. Himmelstein.

Obtaining of funding: D.H. Bor.

Administrative, technical, or logistic support: A.P. Wilper.

Collection and assembly of data: A.P. Wilper.

Ann Intern Med. 2008;149(3):170-176. doi:10.7326/0003-4819-149-3-200808050-00006
Text Size: A A A

Chronic illness is common among persons without insurance. We identified individuals without insurance who had a previous diagnosis of cardiovascular disease (1.3 million), hypertension (5.9 million), diabetes (1.4 million), hypercholesterolemia (4.0 million), active asthma or chronic obstructive pulmonary disease (3.5 million), and previous cancer (1.1 million). We estimate that nearly one third of nonelderly U.S. adults without insurance (that is, 11.4 million individuals) had at least 1 chronic condition. These findings counter notions that persons without insurance are a largely healthy population with little need for ongoing medical care.

First Page Preview

View Large
First page PDF preview


Grahic Jump Location
Study flow diagram.

NHANES = National Health and Nutrition Examination Survey.

Grahic Jump Location




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Re: A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults
Posted on September 9, 2008
Tim J. Stocker
University of California Davis Medical Center
Conflict of Interest: None Declared

We were pleased to see Wilper and colleagues[1] characterize the prevalence of chronic disease among the uninsured, and Dr. Chin's editorial advocating for more quality improvement efforts among vulnerable populations[2]. At the University of California Davis Medical Center, our HRSA-funded Transforming Education and Community Health (TEACH) program includes an inpatient service for uninsured patients run by a dedicated team of internal medicine residents who then assume longitudinal care for these patients in a Sacramento County safety net clinic. Recognizing the paucity of quality improvement efforts for the uninsured, we completed an American Board of Internal Medicine (ABIM) Diabetes Practice Improvement Module[3] which demonstrated that the TEACH clinic performs better than commercial managed care for many intermediate outcomes. Some of the lessons learned from this project may be useful to other community health centers seeking to improve their quality of care[4]:

1. Focus on processes of care and intermediate outcomes. Because of significant migration among uninsured populations (in our study few patients received continuous care over a two year period), hard clinical outcomes may not appreciably change after a given intervention. In contrast, chronic disease processes of care (e.g laboratory testing, dilated eye exams) and intermediate outcomes (e.g. hemoglobin A1c, blood pressure) can quickly improve if patients have access to care and adequate followup.

2. Imperfect data are better than no data. Data collection may be difficult due to ongoing use of paper rather than electronic medical records. Given limited resources, we decided to collect only the most clinically relevant data. Although we left many questions unanswered, we successfully identified several areas for improvement. For example, we found that the TEACH clinic performs worse than commercial managed care for dyslipidemia outcomes because providers do not escalate lipid-lowering therapy aggressively[4]. While academic rigor is important, we suggest first gathering data that is likely to guide future local interventions.

3. Utilize existing quality improvement resources. Quality improvement projects require significant "˜activation energy,' but there are resources available to jumpstart the process. We used the ABIM's Diabetes Practice Improvement Module, which streamlines both study design and data collection. After entering our data into the internet-based software, we received a report summarizing our clinic's processes of care and intermediate outcomes. Although the software has some limitations (it does not export data to conventional statistics applications), overall it greatly facilitated our project.

4. Choose a meaningful comparator. We elected to compare the TEACH clinic's performance to Medicaid and commercial managed care outcomes from the Healthcare Effectiveness Data and Information Set[5]. Medicaid best approximates our patients' socioeconomic status, while commercial managed care reflects usual care for the privately insured. These data sets are limited by lack of patient demographic information, but confounders can be minimized by matching the comparator's inclusion and exclusion criteria. We believe these data sets provide useful quality benchmarks for safety net clinics.

1. Wilper, A.P., et al., A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med, 2008. 149(3): p. 170-6.

2. Chin, M.H., Improving Care and Outcomes of the Uninsured with Chronic Disease . . . Now. Ann Intern Med, 2008. 149(3): p. 206-8.

3. Diabetes Practice Improvement Module. Available from: http://www.abim.org/pims/.

4. Stocker, T.J., Fancher, T.L. Comprehensive Diabetes Care for the Uninsured: Assessing How Internal Medicine Residents Perform. Presented at the Society of General Internal Medicine national meeting. 2008. Pittsburgh.

5. State of Health Care Quality. 2007, National Committee for Quality Assurance: Washington, D.C.

This study was supported by a Health Resources and Services Administration Title VII Grant for Training in Primary Care Medicine and Dentistry (Residency Training in Primary Care Internal Medicine) (D58HP05139-01-00) and the American Board of Internal Medicine F. Daniel Duffy Small Grants program.

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Journal Club
Topic Collections
PubMed Articles
Marshallese COFA Migrants in Arkansas. J Ark Med Soc 2016;112(13):259-60, 262.
[Psychiatry in everyday life]. Cas Lek Cesk 2016;155(4):40-2.
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.