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?"


Harrison said...

Unintended acceleration in Toyotas is blamed for perhaps as many as 60 deaths worldwide.
Intended acceleration in all vehicles killed that many yesterday in the United States alone.
What do we focus Congressional hearings on? Unintended acceleration. Forcing Toyota's CEO to fly here from Japan in order to apologize to a group of Senators in Washington.
Are there things we could do to address Intended acceleration of vehicles.
Of course.
But they would require impositions on individuals who want to drive fast.

Of course there are lots of preventable deaths in the U.S. and of course insurance status plays a role in many of those premature deaths.

But what will make the headlines is the denial of an expensive procedure to someone in need.
What will not get covered is a decision by a state legislature to cut benefits by several months to a whole group of people, and nobody will have the patience to follow up on the outcomes of those disenfranchised people.


Steve Lucas said...

I have to first look beyond the stats. The unemployment rate in my community is 13.5%. The jobs in the mills are gone. What we are left with is a poorly educated population, if you have an education you move. Carbs and starches are a big part of diets do to cost, resulting in a very obese population with a high incidence of diabetes. Smoking and drinking are common as a way to escape the grinding struggle that is daily life.

Many of these people, due to income, receive medical care through a government program. It has become common for young women to have children prior to marriage as a cost savings exercise due to government subsidies. Free clinics are common.

It is also common for the uninsured to use the ER. They feel it saves them time as they do not want to wait in a clinic’s line.

I see the merit in having access to proper medical care, especially for chronic problems such as diabetes. All of the medical care in the world will not make a difference in the lifestyle choices of the people in my community. The result is they will expect to be medicated and thus have all of their medical problems resolved by a pill and a doctor.

I view the problem as one of cost and access. If we can lower the cost, and provide access to those who wish to better their health we should do so, but providing insurance with unlimited benefits will not solve the issue of early death.

Looking at Europe we find they spend about half per person on health care as we do, they also only see patients when they are sick. Insurance in many ways drive cost through over use.

Steve Lucas