The ACP Advocate Blog
by Bob Doherty
Wednesday, March 10, 2010
Is lack of coverage an inconvenience? Or matter of life and death?
One of today's great philosophical divides is whether health reform should seek to provide coverage to all Americans. The Democrats (generally) believe that (near) "universal" coverage must be an explicit purpose of health reform, even if this means spending more and raising taxes to pay for it. Most Republicans (generally) do not have as a goal providing coverage to everyone, especially if this means spending more and raising taxes to pay for it. Instead, the GOP wants to offer more choices and reduce regulation of the insurance industry, such as by selling insurance across state lines, even though this would not make much of dent in the number of uninsured.
But what do we really know about the uninsured? Do most of them already get health care, maybe less conveniently than the rest of us? If so, the moral and economic argument for covering everyone, especially if it will cost up to $100 billion a year, isn't too compelling.
Washington Post columnist Robert Samuelson, a persistent critic of the President Obama's proposal, argues that "The uninsured get care now; with insurance they'd get more" but at a cost that will bankrupt the country. He also says that "Many of today's uninsured get health care for free or don't need much because they're young (40 percent are between 18 and 34)."
But what if he is wrong - that lack of health insurance isn't just an inconvenience, but a matter of life and death? A new study that appeared in the December 22, 2009 issue of the Journal of Public Health and that is reprinted in the current issue of ACP's Journal Club finds that the uninsured are much more likely to die prematurely than those with health insurance. Here's what the authors have to say (warning, some of this gets into arcane statistical jargon):
"A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data. . . We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death. . . . Among all participants, 3.1% (95% confidence interval [CI] = 2.5%, 3.7%) died.
"The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI = 1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio = 1.40; 95% CI = 1.06, 1.84) than those with insurance.
"Conclusion: Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time."
I doubt that this study - and there are others like it - will dramatically change the public or politicians' views of the current health reform proposal. But in a country that is willing to spend untold billions to prevent other avoidable deaths - think highway, car, aviation, food and prescription drug safety, or for that matter, homeland security - I wonder why there is not the same willingness to invest the money needed to prevent people from dying from lack of insurance?
Today's questions: Do you agree that lack of insurance results in premature death? If so, why do you think there is an unwillingness to treat it like other avoidable deaths? Or is it case where "many of today's uninsured get health care for free or don't need much because they're young?"
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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