Effects of health service use and access on the trajectories of self-reported health status and physical functioning

BACKGROUND. Theory postulates that increased health care use or access will lead to better health outcomes, but there exists very little empirical evidence. To date, the literature has primarily focused on health status as a predictor of service use, largely showing that worsening health status leads to increased service utilization and consequently, greater health care costs. Insurance coverage—a key predictor of access to services—has been found to be associated with improved health outcomes, but largely based on cross-sectional studies. Using a longitudinal approach, this study examines the effects of prior health services use and insurance coverage on the change over time in self-reported health (SRH) and physical functioning (PF).

METHODS. This study focused on adults aged 18 and older (n=2,143), using data from the four waves of the Americans Changing Lives Study (1986, 1989, 1994, and 2006). Latent growth curve models were conducted to examine the trajectories for SRH and PF. Using a multi-group approach, we assessed whether prior health service use and insurance coverage moderates the rate of decline in one's health over time. Other key factors that influence health outcomes were also tested, including age, gender, race/ethnicity, income, marital status, education, smoking, body mass index, and chronic conditions.

RESULTS. For the SRH curve, the latent basis model was determined to fit the data well (Χ²=18, df=4, RMSEA=0.04) while for PF, the spline linear model provided the best—but unsatisfactory—fit (Χ²=61; df=4; RMSEA=0.07). Those who used services during the first two waves had a significantly lower initial SRH than those who did not use services (p<0.01). The service user group also exhibited a faster decline in their SRH over time (p<0.01). On the other hand, those who had insurance at wave 2 exhibited both better SRH initially (p<0.01) and slower declines in SRH over time (p<0.01), compared to those who were uninsured. Among insured persons, being married (β=0.12), higher educational attainment (β=0.12), and increased chronic conditions (β=0.29) helped to minimize the decline in SRH.

CONCLUSION. Although one's health is expected to decline over time, results suggest that the rate of decline can be buffered by having health insurance or more generally, broader access to services, earlier in life. Findings emphasize the need to target preventive services towards populations at risk for chronic conditions and with limited economic resources. Such efforts could improve functioning over the lifespan and potentially reduce long-term health care expenditures.