摘要：Objectives. We examined heterogeneous associations between job loss and unmet health care needs by family income level in the recent economic recession. Methods. We conducted logistic regression analyses with the sample from the 2008 Survey of Income and Program Participation (n = 12 658). Dependent variables were 2 dichotomous measures of unmet health care needs in medical and dental services. The primary independent variables were a dummy indicator of job loss during a 2-year period and the family income-to-needs ratio. We used an interaction term between job loss and the family income-to-needs ratio to test the proposed research question. Results. Job loss was significantly associated with the increased risk of unmet health care needs. The proportion with unmet needs was highest for the lowest-income unemployed, but the association between job loss and health hardship was stronger for the middle- and higher-income unemployed. Conclusions. The unemployed experience health hardship differently by income level. A comprehensive coordination of applications for unemployment and health insurance should be considered to protect the unemployed from health hardship. The number of unemployed as a result of the 2007 economic recession was virtually unprecedented in the United States. 1 The unemployment rate increased from 5% in December 2007 to 10% in October 2009 and remained above 9% throughout 2010. An estimated 14 million residents were out of work as of July 2011. 1 Job loss leads to negative shocks to family income and the loss of employer-sponsored health care benefits and increases families’ risk of unmet health care needs. 2 Findings from the 2010 Commonwealth Fund Biennial Health Survey demonstrated that about 60% of the unemployed (9 million of 15 million) became uninsured between 2008 and 2010, 2 exposing their families to the risk of negative health consequences. The public health costs of job loss have been examined extensively in the literature, and the association between unemployment and poor physical and mental health is well established. 3–5 A substantial body of research has indicated strong associations of unemployment with self-rated poor health and somatic illness. 4,6–8 There is also considerable evidence that unemployment is associated with a decline in psychological well-being and the development of mental health problems such as depression, anxiety, substance abuse, antisocial behavior, and unhealthy behaviors. 9,10 Studies have demonstrated a significantly higher hazard of suicide mortality for the unemployed than for the employed after adjusting for potential confounders such as preexisting physical health problems. 11 Although individuals sometimes do lose their jobs owing to their poor health, research has shown that the negative health effects of unemployment are not solely because of this. 8 The negative effects of unemployment on health have been explained with a variety of theories. 8,12,13 For example, the agency restriction model 14 suggests that the main consequence of unemployment is the loss of income, which results in deterioration in well-being, whereas the financial distress and shame model indicates that the shame associated with job loss accounts for the adverse effects of unemployment. 15 Beyond income loss, one of the mechanisms linking unemployment and ill health is the lack of access to affordable and adequate health care. 12,16 It is difficult for the unemployed to afford continued health care coverage. A recent study found that in the United States, only 48% of unemployed individuals had health care insurance compared with about 80% of those employed. 16 The unemployed are also at risk for higher medical expenditures (e.g., out-of-pocket expenses), which adds additional financial pressures to their families. Health services use patterns may have been significantly altered for the unemployed who lost jobs with health care benefits during the recession. For example, even among adults with private health insurance, 15% of those unemployed experienced either a delay or a lack of needed medical care because of cost compared with 9% of those employed, and 9% of the unemployed went without needed prescriptions compared with 5% of those employed. 16 Although unemployed individuals and their families face the challenge of accessing health services, the association of diminished health and no health services with unemployment may differ among various populations. 12,17,18 One of the suggestions to improve the research on health and unemployment 17 is to better understand such heterogeneous impacts of unemployment. For example, it has been suggested that the physical and psychological effects of unemployment probably are greatest in middle age 19 and may disproportionately affect women. 20 Catalano et al. 21 also found that high unemployment predicted reduced detection of local breast tumors differently between African American and non-Hispanic White women. Different reasons may explain the heterogeneous associations of unemployment with health services. Unemployment rates vary by demographic and socioeconomic characteristics. In addition, the negative effects of job loss may be mitigated if the unemployed have sufficient buffering resources (e.g., savings), easy access to public health insurance, and strong social capital (e.g., informal social networks and social support). 22,23 To our knowledge, however, little is known about the heterogeneous associations of unemployment with health services during the recent economic recession. We have begun to fill this gap by focusing specifically on the association between job loss and unmet health care needs by level of family income. Although the association of unemployment with health service use may vary by the level of family income, it is not clear whether lower- or higher-income families suffer more from unemployment. Lower-income families could suffer more from unemployment than do higher-income families because the latter are more likely to have emergency savings, accumulated assets, and access to other resources to buffer income loss and financial strain generated from unemployment. 14,23–25 The lower-income unemployed generally have a higher uninsured rate than do the higher-income unemployed. 2 It is also possible that the higher-income unemployed have a stronger perception of unmet health care needs than do those with lower income, because the higher-income unemployed and their families are more likely to receive the employer-sponsored health care benefits through the job that was lost in the economic recession. 2,12,20 Because health service use is positively associated with family income, higher-income families, as suggested by the cybernetic model, 12 generally have a higher standard or reference goal for “needed health services” and thus have a greater challenge to adapt to a new level of health service consumption after unemployment than do the lower-income unemployed. Gunderson and Gruber 26 distinguished 2 economic stressors—long-term poverty and short-term income shocks—as different determinants of material hardship for low-income and high-income families. From this perspective, unemployment, as a trigger event of negative income shocks, may be more closely associated with unmet health care needs of the higher-income unemployed. In addition to income shocks, the loss of latent benefits from employment, such as time structure, social contact, and socioeconomic status, 12,15,27 possibly results in harder impacts on the higher-income unemployed. Furthermore, the lower-income unemployed are more likely to access public health insurance and other safety net programs than do those with a higher income.
