title: Supplemental insurance and mortality in elderly Americans. Findings from a national cohort.
abstract: BACKGROUND
  As the burden of out-of-pocket health care expenditures for Medicare beneficiaries has grown, the need to assess the relationship between uncovered costs and health outcomes has become more pressing.
  
  
  OBJECTIVE
  To assess the relationship between risk for out-of-pocket expenditures and mortality in elderly persons with private supplemental insurance.
  
  
  METHODS
  Retrospective cohort study using proportional hazards survival analyses to assess mortality as a function of health insurance, adjusting for sociodemographic, access, and case mix-health status measures.
  
  
  METHODS
  The 1987 National Medical Expenditure Survey, a representative cohort of the US civilian population, linked to the National Death Index.
  
  
  METHODS
  A total of 3751 persons aged 65 years and older.
  
  
  METHODS
  Five-year mortality rate.
  
  
  RESULTS
  After 5 years, 18.5% of persons at low risk for out-of-pocket expenditures, 22.5% of those at intermediate risk, and 22.6% of those at high risk had died. After multivariate adjustment, a significant linear trend (P = .02) toward increasing mortality with increasing risk category was observed. Compared with the low-risk group, persons in the intermediate-risk group had an adjusted hazard ratio of 1.2 (95% confidence interval, 0.9-1.6), whereas those in the high-risk group had an adjusted hazard ratio of 1.4 (95% confidence interval, 1.0-1.9).
  
  
  CONCLUSIONS
  Increasing risk for out-of-pocket costs is associated with higher subsequent mortality among elderly Americans with supplemental private coverage. Although research is needed to identify which specific components of out-of-pocket expenditures are adversely associated with health outcomes, findings support policies to decrease out-of-pocket health care expenditures to reduce the risk for premature mortality in elderly Americans.
authors.affiliation: Department of Family Medicine, University of Washington School of Medicine, Seattle, USA. mdoesche@u.washington.edu
authors.forename: M P
authors.initials: MP
authors.lastname: Doescher
authors.forename: P
authors.initials: P
authors.lastname: Franks
authors.forename: J S
authors.initials: JS
authors.lastname: Banthin
authors.forename: C M
authors.initials: CM
authors.lastname: Clancy
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D007354:Insurance, Major Medical / Q000706:statistics & numerical data; D016014:Linear Models; D008297:Male; D009026:Mortality / Q000639:trends*; D016016:Proportional Hazards Models; D012306:Risk; D014481:United States / Q000453:epidemiology