Mea culpa. In a recent posting I stated that the only factor we should care about in considering reform of the system of paying for health insurance is cost. I overlooked one minor detail – the suffering among the uninsured in America. Last month the American Journal for Public Health published a study showing that 45,000 Americans die annually from lack of health insurance. According to an article by Ben Frumin of TPM, over the weekend Senator John Kyl (R-AZ) expressed doubt about the accuracy of that finding. In this posting I discuss the study and its implications for health care financing reform.
The research study examining the link between death rates and health insurance coverage is authored by Doctors Andre Wilper, Steffie Woolhandler, Karen Lasser, Danny McCormick, David Bor, and David Himmelstein. It may be viewed here, and here are links to articles about the study in Harvard Science and Physicians for a National Health Program.
The study begins with these words:
The United States stands alone among industrialized nations in not providing health coverage to all of its citizens. Currently, 46 million Americans lack health coverage. Despite repeated attempts to expand health insurance, uninsurance remains commonplace among US adults.
The authors of the study interviewed and examined over 9000 persons who had participated in a previous Institutes of Medicine study on the link between health and health insurance. The authors controlled for variables such as age, gender, ethnicity, income, education, body-mass index, tobacco use, alcolhol use, and overall health. Taking all of these variables into account, the researchers still found a "significant correlation" (95% confidence level) between lack of health insurance and the risk of death. So far as I can judge, it appears that this study is sound.
Extrapolating the results to the entire population, the researchers found that 45,000 deaths per year in America are attributable to lack of health insurance. According to statistics from the CDC on "Leading Causes of Death," that is about as many people as die from kidney disease, and would make "lack of health insurance" one of the top ten causes of death in the United States.
The authors concluded that lack of health insurance increases an adult's risk of death by 40%. That means that if the death rate among a particular group of insured people is 1%, then the death rate among uninsured people of the same age, gender, ethnicity, income, education, drinking and smoking habits, body-mass index, and general health would be 1.4%. If the death rate among a particular demographic of insured people is 5%, then the death rate among uninsured people of the same demographic would be 7%.
The researchers explained that this increased risk of death among the uninsured is attributable to lack of regular medical care that would otherwise prevent and manage chronic diseases:
The mechanisms by which health insurance affects mortality have been extensively studied. Indeed, the IOM issued an extensive report summarizing this evidence. The IOM identified mechanisms by which insurance improves health: getting care when needed, having a regular source of care, and continuity of coverage. The uninsured are more likely to go without needed care than the insured. For instance, Lurie et al. demonstrated that among a medically indigent population in California, loss of government-sponsored insurance was associated with decreased use of physician services and worsening control of hypertension. The uninsured are also more likely to visit the emergency department and be admitted to the hospital for ‘‘ambulatory care sensitive conditions,’’ suggesting that preventable illnesses are a consequence of uninsurance. The chronically ill uninsured are also less likely to have a usual source of medical care, decreasing their likelihood of receiving preventative and primary care. Discontinuity of insurance is also harmful; those intermittently uninsured are more likely to die than the insured. All of these factors likely play a role in the decline in health among middle-aged uninsured persons detected by Baker et al.
One of the most compelling findings in the report is that the differential risk of death for uninsured people goes down at the age of 65 when everybody qualifies for Medicare. The authors state:
This trend appears to reverse at age 65, when the majority gains access to Medicare coverage.
I suspect that lack of health insurance has an even greater impact on people's quality of life. If deaths are up 40% among the uninsured, I would think that the rate of disability and lack of well-being would be even higher among this group.
My error was to concentrate entirely on the direct monetary cost of extending medical care to everybody – in doing so I failed to take account of the human cost of not providing universal coverage. Even if we strictly focus on economic factors – wealth maximization – we are still paying an enormous price in lost workers, lost productivity, and lost human potential when we neglect to provide adequate health insurance to our population.
{ 3 comments… read them below or add one }
I usually try to avoid talking about economics on a large scale because I don't think government's has a legitimate interest in maximizing societal wealth or productivity, but you can't seriously argue that universal health care is wealth maximizing. The problem is that it would cover more people than is economically efficient. I think our current system is already bad enough. Medicare takes money out of the hands of young, productive people who could be spending that on their own present health care and turns it over to the elderly who, in general, are substantially less productive and have little unrealized potential. All of the health care reform proposals that limit the ratio of old/young insurance premiums would have a similar effect. I think the same could be said for Medicaid as it takes money from people who are productive and gives it to less productive people whose value (as measured by the value others place on their labor) is insufficient to even support their own costs. If we are going to rely on economic justifications to have government-controlled health care, we should make sure were not spending good money on bad people.
Professor,
Notice the logic. You state that there is "a 'significant correlation' between the lack of health insurance and the risk of death". But this correlation is only 95%. Since the death rate is 100%, maybe we would alll be better off without health insurance. This would give us a slight (5%) chance at immortality.
P.O.L.,
Medicare is in place, so people over the age of 65 have health insurance. The reason that the U.S. is falling behind other countries in terms of the general health of the population is precisely because younger people and middle-aged people (and some of us are still productive, by crikey!) aren't receiving the regular, primary care, disease prevention, and chronic disease maintenance that we should. Think of a young person with a knee injury or a 40-year-old woman with diabetes or a 50-year-old man with hypertension, all uninsured or underinsured. And that problem is slated to get much worse, since under the current system over the next decade health care costs are going to double.
Quidpro,
As my mother used to say, "If half a loaf is better than nothing, and nothing is better than heaven, then half a loaf must be better than heaven!"
The correlation is that a person who is uninsured is 40% more likely to die over a particular period of time than an person with identical characteristics. The researchers behind the Harvard Study are 95% certain about that conclusion.