Life and death can be tied to insurance coverage
New study highlights widening divide in care
Independent of other health factors, Americans without private health insurance are significantly more likely to have poorer health and to die prematurely than those with insurance, according to a recent report from the national Institute of Medicine (IOM) in Washington, DC.
The report, the second in what will be a series of six from the IOM’s Committee on the Consequences of Uninsurance, reviewed data from 130 research studies on the effect health insurance status has had on various health outcomes — for example, mortality, overall health and functional abilities.
They found that just being uninsured for one year appeared to diminish a person’s health.
"Because we don’t see many people dying in the streets in this country, we assume that the uninsured manage to get the care they need, but the evidence refutes that assumption," says Mary Sue Coleman, PhD, president of the Iowa Health System and University of Iowa in Iowa City, and co-chair of the committee. "The fact is that quality and length of life are distinctly different for insured and uninsured populations."
Among the key findings:
• Studies of mortality among comparable groups of adults document approximately a 25% higher risk of premature death among those who are without health insurance at the beginning of the study period.
• Uninsured adults are much less likely than adults with any kind of health insurance to receive the screening and preventive services recommended by the U.S. Preventive Services Task Force.
• Over relatively short periods of time — one to four years — uninsured adults or adults who lose insurance temporarily are more likely to have diminished health than are those who remain continuously insured.
• Uninsured cancer patients are generally in poorer health and are more likely to die prematurely than are persons with private insurance, largely because of delays in diagnosis. For example, uninsured women with breast cancer have a 30%-50% higher risk of dying than women with private health insurance.
• Having health insurance of any kind has been shown to reduce the risk of dying in the short term by 71%-85% percent among HIV patients.
Although it has been conventional wisdom for years that insured patients have access to more and better health care, the extent to which that access to premium care translated into significantly better overall health was surprising to the researchers, says Coleman.
"One of the things that I was surprised about is the magnitude of the effects, particularly the magnitude of the effect in the decline in health status of people going without health insurance for just one to four years," she says.
Problems not just with chronic disease
Although many of the poorer health outcomes can be traced back to lack of preventive health and screening services that detect symptoms of chronic and terminal disease early, this does not account for all of the differences in health status, researchers note.
The committee also looked at treatment of traumatic injuries and heart attacks in hospital settings: two conditions for which most people are treated regardless of whether they are insured or not.
Researchers found that uninsured people with traumatic injuries are less likely to be admitted to the hospital, receive fewer services if they are, and are more likely to die than insured victims.
One statewide study of car crash victims found that uninsured victims had a 37% higher mortality rate. Another study found that although uninsured trauma patients were just as likely to be placed in intensive care, they were less likely to be operated on or to receive physical therapy.
"The studies we review don’t address the specific reasons why that happens, but from my own personal experience, I know that insurance is a major factor from the point people enter the health care system anywhere in the United States," says John Ayanian, MD, MPP, associate professor of medicine and health care policy at Harvard Medical School in Boston and IOM committee member. "It is often one of the first pieces of information that is obtained from them, what their insurance status is."
Studies showed that uninsured heart attack patients had a greater risk of dying during their hospital stay or shortly thereafter than patients with private insurance. They are also less likely to go to a hospital that performs angiographies or other catheterization techniques. But even if they do, they are less likely to receive such sophisticated procedures, the report indicates.
These studies document that, when uninsured patients present to the hospital, they are receiving a different level of care, Ayanian states. "In part, it may be that it is more difficult to transfer patients to other hospitals, for instance, to receive cardiac surgery when they need it. One of the studies we reviewed addressed that point and showed that if you were admitted to a hospital without cardiac surgery services, it was harder to get transferred if you were uninsured."
Report underestimates true numbers
Because the report only examined studies of insured and uninsured patients who already had serious health complications, it is likely that it underestimates the true health risks posed by lack of access to insurance, Coleman says.
The studies cannot account for the experiences of those who do not seek treatment, and other studies have shown that uninsured adults are less likely to seek treatment, she says. "Because people can’t be studied unless they get access somewhere in the system, these are probably underestimates."
The report should not be seen as criticizing people who do not purchase insurance, or of hospitals or internists or any other specific group of health care providers, researchers say, because the large numbers indicate the problem is with the healthcare system as a whole.
"This is a major American phenomenon and problem," says Reed Tuckson, MD, another committee member and senior vice president for consumer health and medical advancement at United HealthGroup in Minnetonka, MN. "What our report focuses on are the consequences of that infrastructural problem."
Overall, researchers argue, the data shows that health insurance strategies that target the entire uninsured population would be more likely to produce greater health benefits and increase life expectancy than rescue programs aimed only at the seriously ill.
Uninsured minorities at greater risk
Being uninsured magnifies the health risks for chronically sick and mentally ill patients, as well as for groups that are already at greater risk of poor health, such as racial and ethnic minorities and adults with low incomes, the committee wrote.
Reducing disparities in insurance coverage would reduce some, but not all, disparities in health care experienced by racial and ethnic minorities.
The full report is available on the web site of the National Academy Press at www.nap.edu.
Sources
- Mary Sue Coleman, PhD, University of Iowa, Iowa Health System, Office of the President, Iowa City, IA 52242.
- Reed Tuckson, MD, United HealthGroup Center, 9900 Bren Road E., Minnetonka, MN 55343.
- John Ayanian, Harvard Medical School, Department of Health Care Policy, 180 Longwood Ave., Boston, MA 02115.
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