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THE UNINSURED MORE LIKELY TO DIE PREMATURELY
Uninsured Americans are more likely to have poorer
health and die prematurely than those with insurance, says a report from the
National Academies' Institute of Medicine in 2002. Uninsured patients with cancer face up to a 50 percent greater chance of dying than patients with
private health insurance. Uninsured victims of trauma also are more likely to die from
their injuries. Being uninsured for even a year appears to diminish a person's
general overall 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," said Mary Sue Coleman, co-chair of the committee that
wrote the report, and president, Iowa Health System and University of Iowa, Iowa
City. "The fact is that the quality and length of life are distinctly different
for insured and uninsured populations."
The committee examined the consequences of being uninsured for people suffering
from cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental
illness, traumatic injuries, and heart attacks. It focused on the roughly 30
million -- one in seven -- working-age Americans without health insurance. This
group does not include the population over 65 that is covered by Medicare or the
nearly 10 million children who are uninsured in this country. A future report
will look at how the lack of health insurance affects children and pregnant
women.
Adults with public coverage, such as Medicaid, are a distinct group as well
since they tend to be in significantly worse health than those with private
insurance and even in somewhat worse health than those with no insurance. Adults
qualify for Medicaid because they are poor or have already incurred unaffordable
medical expenses. In addition, low-income adults eligible for Medicaid often do
not apply for it until they are sick.
Uninsured cancer patients die sooner than people with insurance do, largely
because of delayed diagnosis, the report says. The uninsured are less likely to
receive timely screening services such as mammograms, Pap tests, and colon
exams. By the time cancer is diagnosed in uninsured patients, it is more likely
to be at an advanced, often fatal, stage. Likewise, uninsured patients tend to
reach severe renal failure before they begin kidney dialysis.
The longer diabetics go without health insurance, the greater the chance they
will experience uncontrolled blood-sugar levels, the report says. Studies show
that 25 percent of adult diabetics who were uninsured for a year or more went
without a checkup for two years, compared to 5 percent of diabetics with
insurance. Uninsured diabetics also are less likely to receive regular foot and
eye exams, which can help prevent blindness and amputations.
Uninsured adults with hypertension or high cholesterol are less likely to
monitor their blood pressure or stay on drug therapy -- if they are fortunate
enough to be screened at all, the report says. Patients admitted to emergency
rooms with severe uncontrolled hypertension are more likely to be uninsured.
Uninsured adults with HIV infection or AIDS are less likely to receive the
highly effective "drug cocktails" that have become the standard treatment in the
past five years, the report says. And when they do get the newer drug therapies,
their wait to receive treatment has been an average of four months longer than
that of patients with private insurance. Providing health insurance to HIV and
AIDS patients has been shown to significantly reduce death rates.
"It wasn't difficult for us to conclude that if the uninsured became insured on
a continuous basis, their health would improve and they would live longer," said
committee co-chair Arthur Kellermann, professor and chair, department of
emergency medicine, and director, Center for Injury Control, Emory University
School of Medicine, Atlanta.
Mentally ill patients with insurance that covers their treatment are more likely
to receive appropriate care than those with no insurance, the report says. Even
when health insurance does not specifically cover mental-health expenses, just
having it increases the likelihood that someone with depression or anxiety will
receive some care. People with severe mental illnesses such as schizophrenia or
bipolar disorder have trouble keeping health insurance coverage after diagnosis
because they have difficulty holding down jobs. Until they gain public insurance
coverage, these patients face delays in receiving appropriate services.
To see how uninsured patients fare in a hospital setting, the committee focused
on two conditions for which most people are treated regardless of whether they
are insured: traumatic injuries and heart attacks. It found that uninsured
persons 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 discovered that uninsured
victims had a 37 percent higher mortality rate. Another statewide 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.
Research also shows that uninsured patients hospitalized for a heart attack have
a greater risk of dying during their hospital stay or shortly thereafter than
patients with private insurance. They also are less likely to go to a hospital
that performs angiography or other catheterization techniques, and even if they
do, they are less likely to receive such sophisticated procedures.
Studies that have monitored the health of people who had no insurance or
temporarily lost it for a period of one to four years show that a person's
overall well-being suffers during the time they lack coverage. The decline in
health caused by a lack or loss of coverage is most profound for adults between
55 and 65 years old, the report says. Symptoms of worsening health might include
high blood pressure, greater difficulty climbing stairs or walking, or a decline
in general self-perceived wellness.
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, the committee said.
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
said. It added that increasing health insurance coverage would reduce some, but
not all, of the disparities in health care experienced by racial and ethnic
minorities.
The committee noted that the research literature on which it based its findings
probably understates the differences in health outcomes between insured and
uninsured adults. The studies cannot account for the experiences of those who do
not seek treatment, and uninsured adults are less likely to seek treatment.
The report is the second of six that will constitute an extensive review of
research intended to paint an accurate portrait of who lacks health insurance
and why, along with the personal, social, and economic consequences. Rather than
add to the many policy recommendations already on the table, the study is
designed to lay the groundwork for a more informed and productive public debate
about health care coverage. The committee's final report, however, will identify
promising strategies for addressing the problems of uninsurance in the United
States.
The study is being sponsored by the Robert Wood Johnson Foundation. The
Institute of Medicine is a private, nonprofit institution that provides health
policy advice under a congressional charter granted to the National Academy of
Sciences. A committee roster follows.
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