Haves and Have-Nots: Gaps Widen in Control of BP Among Insured and Uninsured

May 20, 2014

NEW YORK CITY, NY — Among individuals with health insurance in the US, the percentage of those with adequate control of their blood pressure increased in recent years, while there's been no change in the percentage of individuals without insurance who had blood-pressure levels at the guideline-recommend targets[1].

As a result, those without insurance are falling behind and not benefiting from advances in hypertension care, say researchers.

The findings, from the National Health and Nutrition Examination Surveys (NHANES), were reported here at the American Society of Hypertension (ASH) 2014 Annual Scientific Meeting by Dr Brent Egan (University of South Carolina, Charleston).

In 1988–1994, there was no statistically significant difference in the number of patients with insurance and without insurance who were at the recommend blood-pressure goal of less than 140/90 mm Hg. During this time, 25.6% of those without insurance and 28.5% of those with public or private insurance were at the blood-pressure target. In the latest NHANES analysis from 2005–2010, however, the percentage of insured patients who achieved the blood-pressure target increased to 52.5%, while hypertension control was achieved in just 29.8% of those without insurance.

"There was a very strong and clear increase in blood-pressure control in insured patients and no change in the uninsured," said Egan. "They fell progressively behind the insured population."

What Is Driving the Gap Between the Groups?

Investigators also attempted to analyze the factors contributing to the discrepancy between the insured and uninsured patients and found that the uninsured patients were less likely to be aware they had hypertension, less likely to be treated when they were aware, and less likely to be controlled when they were treated. "Each of these three factors contributed roughly equally to the difference between the insured and uninsured patients with blood-pressure control," said Egan.

The percentage of insured patients who visited a physician 0 to 1 time in the past year decreased from NHANES 1988–1994 to 2005–2010. Approximately 80% of the insured patients in the latest survey were seeing a physician at least twice per year. Comparatively, in the uninsured population, 50% in 1988–1994 saw a physician two or more times per year, and this did not change in 2005-2010 survey.

In presenting the findings, Egan said there will remain a large number of US adults without insurance, estimated to be around 31 million people, despite the introduction of the Affordable Care Act (ACA). "We think this is a major problem because this population is growing," he said. "They have not benefited from advances in hypertension control over time. It appears to us that either private or public insurance for uninsured individuals will be a key step in eliminating these differences."

During the panel discussion, Dr Venkata Ram (University of Texas Southwestern Medical Center, Dallas) said the findings highlight how far physicians have come in getting patients to goal but are a sobering reminder of just how much more work needs to be done. He asked Egan about deductibles and whether or not they examined the influence of out-of-pocket expenses on blood-pressure control. While Egan said they did not, the data show that these payments do influence adherence, even among individuals with insurance.

Dr Clarence Grim (High Blood Pressure Consulting, Stateline, NV), who was not involved in the study, said studies published more than 30 years ago have shown significant reductions in mortality can be achieved by reducing high blood pressure with a clinic designed around access. This includes free treatment, free transportation to and from the clinic, and free medication.

Egan agreed. "This is the issue," he said. "It's about access to care, regular use of care, and systematic treatment—I absolutely agree with you. We've had this information for 30 plus years and we've really done nothing with it. What we've seen, as I say, is a dramatic gap occurring between the insured and uninsured. There is now an absolute 20% gap between these groups in terms of blood-pressure control."

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