Does free care improve adults' health? Results from a randomized controlled trial.

Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost? In an effort to answer this question, we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been randomly assigned to a set of insurance plans for three or five years. One plan provided free care; the others required enrollees to pay a share of their medical bills. As previously reported, patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often. For persons with poor vision and for low-income persons with high blood pressure, free care brought an improvement (vision better by 0.2 Snellen lines, diastolic blood pressure lower by 3 mm Hg); better control of blood pressure reduced the calculated risk of early death among those at high risk. For the average participant, as well as for subgroups differing in income and initial health status, no significant effects were detected on eight other measures of health status and health habits. Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence, favorable or adverse, of free care for the average participant. For some measures of health in subgroups of the population, however, the broader confidence intervals make this conclusion less certain.

How sophisticated are consumers about the medical care delivery system?

A 10-item questionnaire was administered to non-elderly persons (N = 4,976) to measure their sophistication or knowledgeability about the medical care delivery system. Such sophistication seems germane to views about the appropriate role consumers might play in decisions affecting resource allocation, especially whether competition or cost-sharing strategies should be pursued or whether certain regulatory strategies are more promising. Analyses of individual items suggest that consumers are knowledgeable about some matters and uninformed about others. If a pro-competitive strategy is pursued, efforts at educating consumers about board certification, staff privileges and other information pertinent to choosing a regular source of care seems warranted. Factor analyses indicated that a substantial amount of the information contained in item responses can be summarized in a multi-item scale score. The reliability and validity of this scale as a measure of patient sophistication was supported.

Measuring components of children's health status.

Measures of physical, mental and social components of health status and general health ratings were studied for children ages 0-4 (N = 679) and 5-13 (N = 1473). Questionnaires were completed by adult proxies (usually mothers) in three generally healthy populations. Hypothesized multi-item scales were tested; reliability was estimated and preliminary attempts at validation were undertaken. Items in ten scales pertaining to mental health (Anxiety, Depression, Positive Well-Being, Mental Health Index), social health (Social Relations), general health ratings (Current Health, Prior Health, Resistance/Susceptibility to Illness, General Health Rating Index), as well as parental satisfaction with child development satisfied Likert-type and discriminant validity criteria. Because functional limitation items were endorsed for very few children, scales to measure physical health could not be tested. Almost all scales were sufficiently reliable for group comparisons; reliability coefficients were lower in the most disadvantaged population. Interrelationships among scales and validity variables generally supported their construct validity and supported a multi-component model of children's health status.