Health insurance, or particularly its lack, and healthcare consequences among hypertensive Americans

The United States enjoys a somewhat dubious distinction among industrialized countries as the only nation without single-payer health insurance. The adverse consequences of this shortcoming are well documented. The extent to which this contributes to the fact that less than half of all American hypertensive persons achieve blood pressure control is well known.1 Less well recognized may be that aspects of our disjointed healthcare system may also actually cause harm.2 The 15% of Americans without health insurance are at particular risk of missing cardioprotective health services. Hypertension is asymptomatic. It tends to begin during the most productive and busy times in the lives of both men and women. Our fee-for-service system, by design, discourages routine, chronic, and poorly rewarded medical care, while raining vast sums on episodic procedure-oriented treatments. The great majority of those aged 40–60 years who feel well and are able to fully participate in the activities of ordinary life have little incentive to visit a physician. In this issue of the Journal, Fang and colleagues at the US Centers for Disease Control and Prevention have provided a window into the magnitude of the problem of dissociation of those who are aware of their hypertension from the medical care system.3 By examining BFFRS data, in a regularly collected sample representative of the health-related behaviors of all Americans, 25% of the >19,000 self-identified hypertensive citizens had not visited a physician in the past year. These folks were characterized by lack of insurance, low income, inadequate education, minority status, and barriers to access to medical care. The study population was defined by self-reported hypertension and thus probably underestimates the actual number of hypertensive persons without a link to medical care. Thus, one-fourth of these aware of their hypertension may have only encountered a sphygmomanometer in a setting that did not ensure progression to ongoing appropriate care. For these potential patients, the only impact of knowing (awareness) could be unrelieved anxiety. These aware but unconnected millions of Americans miss the opportunity to reduce their risk of stroke and heart attack. But, they may also be disadvantaged in their quality of life. There is evidence that these hypertensive persons are disadvantaged in both their occupational and private lives, when compared with treated and controlled confreres.2 Not surprisingly, this does not have to be.4 Fang also found that 90% of those eligible for Medicare had seen a physician within the past year. Presumably, access to medical care could have led to fewer strokes and heart attacks—and improved quality of life. Perhaps implementation of the Affordable Care Act (Obamacare) will narrow the gap between those who know of their need but lack appropriate service and those who have access and can attain effective antihypertensive treatment. Although this will not resolve the continuing failure of nearly half of even treated patients to achieve success, it would be an important step in the right direction.