title: The impact of insurance instability on health service utilization: does non-metropolitan residence make a difference?
abstract: OBJECTIVE
  Discontinuous and no health insurance are major barriers to health care utilization. This paper examines if nonmetropolitan versus metropolitan residence is associated with differences in health care utilization in the face of insurance instability.
  
  
  METHODS
  A cross-sectional analysis of adults aged 18-64 years was conducted using the 2006-2010 Medical Expenditure Panel Survey data set (N = 61,039). Negative binomial regression was used to model measures of health service utilization (emergency room [ER] visits, inpatient discharges, office-based visits, dental care visits, prescriptions filled, home health visits) as functions of insurance continuity, adjusted for sociodemographic and health-related covariates. Models were stratified by metropolitan versus nonmetropolitan residence.
  
  
  RESULTS
  Health insurance continuity was significantly associated with several measures of health service utilization, including more ER visits for individuals with gaps in health insurance (IRR [incident risk ratio] = 1.29; 95% CI: 1.16-1.42) and fewer inpatient discharges for individuals without insurance (IRR = 0.50; 95% CI: 0.43-0.57) when compared with individuals with continuous insurance. Individuals who were discontinuously insured or uninsured had significantly fewer office-based visits. They also had significantly fewer dental visits, prescription fills, and home health visits; moreover, the magnitudes of these associations were generally significantly greater for residents of nonmetropolitan areas.
  
  
  CONCLUSIONS
  Insurance instability is associated with higher use of emergency services and reduced use of nonhospital health care services. Residents of nonmetropolitan areas with unstable or no insurance coverage may be at particular risk for reduced access and use of some health services relative to their counterparts living in metropolitan areas.
authors.affiliation: Betty Irene Moore School of Nursing, University of California Davis, Sacramento, California.
authors.forename: Bronwyn E
authors.initials: BE
authors.lastname: Fields
authors.forename: Janice F
authors.initials: JF
authors.lastname: Bell
authors.forename: Sally
authors.initials: S
authors.lastname: Moyce
authors.forename: Jeri L
authors.initials: JL
authors.lastname: Bigbee
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000592:standards* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires
keywords: Medical Expenditure Panel Survey; geography; health disparities; health services research; insurance