摘要：Objectives . We analyzed state-specific uninsurance trends among US adults aged 18 to 64 years. Methods . We used logistic regression models to examine Behavioral Risk Factor Surveillance System data for uninsurance from 1992 to 2001 in 47 states. Results . Overall, uninsurance rates increased in 35 states and remained unchanged in 12 states. Increases were observed among people aged 30 to 49 years (in 34 states) and 50 to 64 years (in 24 states), and increases were also observed among individuals at middle and low income levels (in 39 states and 19 states, respectively), individuals employed for wages (in 33 states), and the self-employed (in 18 states). Conclusions . Among adults aged 18–64, rates of uninsurance increased in most states from 1992 through 2001. Decreased availability of employer-sponsored health insurance, rising health care costs, and state fiscal crises are likely to worsen the growing uninsurance problem. Lack of health insurance has been a longstanding concern in the United States, 1 especially because uninsurance has well-documented negative consequences for the public’s health. 2– 4 Furthermore, uncompensated care provided to uninsured individuals strains a health care system that is struggling to meet the escalating costs of new technologies and treatments as well as the health care needs of an aging population. 5 Historically, employment and health insurance status in the United States have been closely linked. 6 Although percentages have generally declined over time, 6 nearly 63% of people with insurance are covered through employment-based policies. 7– 10 The United States experienced its longest peacetime economic expansion during the 1990s, with the national unemployment rate declining substantially over this period. Despite this economic expansion, there was little change in national uninsurance estimates; uninsurance increased from 15.0% in 1992 to 16.3% in 1998 and then decreased to 14.6% in 2001. 7, 11, 12 However, recent reports suggest that uninsurance is increasing among individuals at middle and high income levels and among those aged 50 to 64 years. 7, 13– 15 But national data can mask important variations in uninsurance across states. According to 3-year state averages calculated for the period 1999 through 2001, uninsurance rates ranged from 7.2% in Rhode Island to 23.2% in New Mexico. 7 States have different demographics, economies, and policies for public funding of health insurance, all of which contribute to levels of uninsurance. 6 For example, some states enacted measures to broaden health care access during the 1980s and 1990s. 16, 17 To date, only a few state-level analyses of uninsurance trends during the 1990s have been conducted, primarily based on Current Population Survey (CPS) data. 7, 9, 12, 18, 19 Unfortunately, CPS data must be pooled across years, because annual sample sizes are small for many states 8 and extensive changes in survey wording made in 1995 have raised concerns about the accuracy of trend analyses. 8, 20 Other ongoing federal and privately funded research data collection efforts have not been designed to track state-level trends in uninsurance, 8 have included data from only a limited number of states, 8 or have examined changes in health insurance during this time period on populations in only a few states or metropolitan areas. 8 Little is known about broader, population-wide trends in uninsurance among adults at the state level, especially in the case of certain demographic subgroups (e.g., groups categorized according to age or employment status) among which uninsurance estimates are known to vary widely. 21, 22 With most states currently facing fiscal difficulties, rising unemployment, and increasing health care costs, and with the burden of paying for uninsured health care falling disproportionately on state and local governments, detailed state trend data are needed to describe the extent of the uninsurance problem among adults and help guide policymakers’ efforts. State-specific adult data on uninsurance are available from the Behavioral Risk Factor Surveillance System (BRFSS), which has used the same question over time to gather information on insurance status. We analyzed BRFSS data from 1992 through 2001 to assess state uninsurance trends among adults aged 18 to 64 years. We limited our analyses to these ages because most adults aged 65 years or older are covered by Medicare. 7, 12 In addition to overall state uninsurance trends, we also examined state-specific trends according to age group, household income, and employment classification.
