HEALTH LITERACY & DISPARITIES IN HEALTH INSURANCE COVERAGE: INSIGHTS FOR HEALTH SYSTEM REFORM IN THE UNITED STATES

Introduction

Data & MethodsFramework

Results

Implications

R.V. RikardPostdoctoral Research Associate

Department of Media & InformaitonMichigan State University

rvrikard@msu.edu

Julie McKinneyHealth Literacy Specialist

McKinney & Associates Health Literacy Consultingjmckinney11@gmail.com

Maxine ThompsonAssocaite Professor

Department of Sociology & AnthropologyNorth Carolina State UniversityMaxine_Thompson@ncsu.edu

Low health literacy is linked to poor health outcomes, overuse of emergency medical services, higher health care costs and health disparities between groups with diff erent racial and socioeconomic backgrounds.

However, few studies examine the relationship between health literacy and disparities in health insurance coverage using a nationally representative sample of adults in the United States.

• The research employs the restricted access data from the 2003 National Assessment of Adult Literacy (NAAL).

• The analytic sample is limited to adults 18 to 64 years of age as older adults (i.e., 65 and older) are automatically qualifi ed for health insurance under Medicare in the United States United States (N = 13,080).

• A series of weighted logistic regression models estimate the mediating eff ect of health literacy level and health insurance coverage.

• A separate set of regression models examine the conditional eff ect of sex and then race/ethnicity on the likelihood of health insurance coverage.

The research contributes insight for the implementation of the 2010 Patient Protection and Aff ordable Care Act (ACA):

1. Low health literacy is associated with factors, such as employment status, poverty, U.S. citizenship, that predict health insurance coverage. Therefore, interventions to improve health literacy will require system more than a “scatter-gun” approach at the individual level.

2. Health literacy initiatives will require systemic changes in the systems of healthcare, health insurance, and preventive care. Thus, our fi ndings support development of initiatives for those in most need to improve the health literacy skills needed to access and use health insurance.

3. Successful initiatives will focus on improving health literacy and increasing access to health insurance by connecting individual needs to health systems resources.

Figure 1 is the conceputal model of our analyses. The black arrows represent direct eff ects and the grey arrows represent indirect eff ects. We hypothesize direct relationships between demographic characteristics, fl exible resources, social resources and health insurance status. In addition, we hypothesize that health literacy level mediates the relationship between the predictors and health insurance status. We also expect that the eff ect of health literacy level is mediated by social support and literacy self-effi cacy.

• Health literacy level does not mediate the relationship between demographic, socioeconomic status, relational social class, social resources and health insurance coverage.

• However, health literacy level directly eff ects health insurance coverage. NAAL respondents are 11 percent more likely to heave health insurance as their health literacy score increases.

• Direct signifi cant eff ects that increase the likelihood of health insurance coverage include: median household income, extra income from savings/investments, higher level of educational attainment, full-time employment, voting in the 2000 election, and marriage/living as married.

• The conditional analyses by sex reveals that women are more likely to have health insurance as their average health literacy level increases compared to men. Speicifcally:

• African-American women are more likely to have health insurance compared to White women.

• However, there is no signifi cant diff erences in the likelihood of health insurance status between African-American and White men.

• There is a signifi cant diff erence in the likelihood of health insurance coverage between African-American women and men. In other words, African-American women are more likely to have health insurance compared to their male counterparts.

• Foreign born Hispanic/Latino women and men are less likely to have health insurance compared to White women and men, respectively.

1. Sentell’s (2012) research reveals that low health literacy predicts lack of health insurance in adults, even when demographic, socioeconomic, employment status, and availability of employer-based insurance are taken into account.

2. Yin & colleagues’ (2009) research indicates that health literacy level mediates the relationship between race/ethnicity, educational attainment level, poverty status, and English profi ciency and lack of health insurance controlling for other demographic and socioeconomic characteristics.

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of our research.

ReferencesBlumberg L.J., Long, S.K. Kenney G.M., & Goin, D. (2013) Public Understanding of Basic Health Insurance Concepts on the Eve of Health Reform. Urban Institute Health Policy Center.

Link, B. G., & Phelan, J. C. (1995). Social Conditions As Fundamental Causes of Disease. Journal of Health and Social Behavior, 35, 80-94.

Sentell, T. (2012). Implications For Reform: Survey Of California Adults Suggests Low Health Literacy Predicts Likelihood Of Being Uninsured. Health Aff airs, 31(5), 1039-1048.

Yin, H. S., Johnson, M., Mendelsohn, A. L., Abrams, M. A., Sanders, L. M., & Dreyer, B. P. (2009). The health literacy of parents in the United States: a nationally representative study. Pediatrics, 124(Supplement 3), S289-S298.

Yet, little research specifi cally focuses on health literacy and diff erences in health insurance coverage by sex and race/ethnicity taking into account other predictors.

Research Questions:

1. Are there diff erential relationships between demographic groups, access to fl exible resources, social resources and health insurance status?

2. If disparities exist, does health literacy mediate the the observed diff erences?

Figure 1

Conceptual Model

Recent research (Blumberg et al., 2013) suggests that nearly 2 out of 3 adults specifi cally targeted for enrollment in the health insurance Marketplaces report gaps in their understanding of basic health insurance concepts.

Share of Consumers Most Likely to Use Health Insurnace Exchanges Who Are Very or Somewhat Confi dent in Their Understanding of Basic Insurance Terms

Source: Health Reform Monitoring Survey, Quarter 2 2013. Adadpted from: Blumberg L.J., Sharon K. Long, Genevieve M. Kenney, and Dana Goin (2013) “Public Understanding of Basic Health Insurance Concepts on the Eve of Health Reform” Urban Institute Health Policy Center. Notes: The exchange target population is nonelderly adults with family income above 138% of the federal poverty level who either had nongroup coverage or were uninsured at the time of the survey. Health status is self-reported. Basic insurance terms include permium, deductible, co-payments, coinsurnace, maximum annual out-of-pocket spending, provider netowrk, covered services, annual limits on services, and excluded services.** / *** Estimate diff ers signifi cantly from the reference group. denoted by ^, at the 0.05/0.01 level, using two-tailed tests.

The “fundamental cause” framework (Link & Phelan 1995) proposes that access to fl exible resources (e.g., money, knowledge, power, prestige, social support and social networks) decreases the risk of being at risk for illness and early death.

Resources directly shape individual health behaviors by infl uencing whether people know about, have access to, can aff ord, and are supported in their eff orts to engage in health-enhancing behaviors.