Thousands die each year in US because they lack health insurance

By Jerry Isaacs
25 May 2002

More than 18,000 Americans die every year solely because they cannot afford private health care insurance. This is the finding of a new study entitled “Care without coverage: Too little, too late,” which compares the health of insured and uninsured adults in the US, where 30 million—or one out of every seven—working-age people lack health care coverage.

The study, conducted by the Institute of Medicine (IOM), a private organization affiliated with the National Academy of Sciences, paints a chilling picture of the consequences of America’s for-profit health care system. More than 40 million people, including nearly 10 million children, have no health insurance, and the number continues to grow at a pace of about 1 million each year.

Those without health insurance are more likely to have poorer health and die prematurely than those with insurance, the study found. Uninsured adults received fewer diagnostic and treatment services after traumatic injuries or heart attack, resulting in an increased risk of death even when in the hospital. People without insurance also more often go without cancer screening tests, delaying diagnosis and leading to premature death, the study concluded.

Those without insurance also do not receive care recommended for chronic diseases, like regular eye and foot exams to prevent blindness and amputation in persons with diabetes, and lack regular access to medications to manage conditions such as hypertension or HIV infection.

All told, the IOM study found, 18,314 people die each year because they lack preventative services, a timely diagnosis or appropriate care. This includes about 1,400 people with high blood pressure, 400 to 600 with breast cancer and 1,500 diagnosed with HIV. Odds are the number of deaths is even higher.

“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 of the 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,” she said.

The uninsured are disproportionately lower income workers whose employers do not provide medical insurance. At the same time they do not qualify for Medicaid, the federal health care program for the poor. Adults on Medicaid tend to be in even worse health than those with no insurance at all.

According to the IOM study, 39 percent of those making $20,000 or less are uninsured, while another 20 percent had their coverage interrupted at some point over the course of the last two years. The lack of health care is also an acute problem for those earning more. Fourteen percent of those making between $20,001 and $35,000 are uninsured, while another 17 percent had a recent gap in coverage. Among those making between $35,000 and $60,000, 4 percent were uninsured and another 9 percent went without coverage some time over the last two years.

Studies monitoring 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.

Cancer, HIV and other diseases

Cancer patients without health insurance have qualitatively less hope for survival. Uninsured patients with colon or breast cancer face up to a 50 percent greater chance of dying than patients with private coverage, according to IOM researchers. Uninsured adults are less likely to receive recommended mammograms, clinical breast exams, Pap tests and colorectal screenings. If they do it is with far less frequency.

Uninsured cancer patients generally have poorer outcomes and die sooner than persons with insurance. “Without timely preventative screenings, diagnosis is delay. As a result, when cancer is found, it is relatively advanced and more often fatal that it is in persons with health insurance coverage,” the report states. Uninsured women with breast cancer, for example, have a 30 to 50 percent higher risk of dying. Furthermore, the report notes, “once diagnosed, treatment disparities persist. For example, uninsured women are less likely to receive breast-conserving surgery.”

The study examined five chronic conditions, which highlight the inferior treatment the uninsured receive and poorer outcomes that result. These include:

Diabetes: Uninsured adults with diabetes are less likely that those insured to receive the standard of care needed to monitor blood glucose levels and other complications. Uncontrolled blood glucose levels put a person at greater risk for heart and kidney disease and amputations and blindness. One in four diabetics goes without a checkup for two years if they have been without health insurance for a year or more.

Cardiovascular disease: 19 percent of uninsured adults diagnosed with heart disease and 13 percent with hypertension lack regular monitoring of their medical condition. Their blood pressure and cholesterol levels are checked less frequently, and they are less likely to be or stay on drug therapy than insured adults. 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.

Kidney disease: Uninsured patients have more severe kidney failure when they begin dialysis and their health is often already compromised because they did not receive treatment for anemia before initiating dialysis.

Human Immunodeficiency Virus (HIV) infection: Without health care insurance, many HIV patients wait more than three months after diagnosis to have their first office visit. The uninsured wait an average of four months longer to receive new drug therapies, and once they start medication, they are less able to maintain the costly and complicated drug regimen. Having medical insurance appears to reduce mortality rates among HIV-infected adults by 71-85 percent over a six-month period.

Mental Illness: Without specific coverage for mental health visits, patients diagnosed with depression, panic disorder or generalized anxiety disorder are less likely to receive any care. Having general health insurance, even without mental health benefits, increases the likelihood of receiving some care.

The Institute of Medicine even concluded that victims of severe trauma, such as motor vehicle accidents, are less likely to be admitted to a hospital, receive fewer services when admitted, and are 37 percent more likely to die than insured trauma victims. One statewide study showed that while uninsured trauma patients were as likely to receive intensive care unit services as privately insured patients, they were less likely to undergo surgical procedures or receive physical therapy.

The IOM concludes that the health and length of life of working-age Americans, particularly minorities and lower-income workers, would greatly improve if they obtained medical coverage. “Like those who are now insured, the newly insured would use preventative services more often and would be less likely to delay seeking care, thus making early detection and treatment of problems more feasible. The best health outcomes are possible only if the uninsured obtain coverage before the onset of any illness or injury.”

Summing up these findings committee co-chair Arthur Kellermann, from the Center for Injury Control, Emory University School of Medicine in Atlanta, said, “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.”

The suggestion that health care coverage should be extended to everyone in the US, however, cuts across the economic interests of the insurance, hospital and pharmaceutical corporations that dominate the health care system and is therefore bitterly opposed by the political establishment. All but conceding this, IOM concludes that while health care insurance provides “financial security and stability, peace of mind, alleviation of pain and suffering, improved physical function, disabilities avoided or delayed, and gains in life expectancy,” the reality is that for “many of the 30 million uninsured adults and another 9 million children in America, these benefits remain elusive.”

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