US poor and uninsured suffer substantially worse health outcomes

By Naomi Spencer
5 January 2008

Two newly released studies provide further confirmation that poor and uninsured people in the US suffer significantly worse health outcomes than those who have medical coverage. The studies suggest that for people with cancer, cardiovascular disease, diabetes and other high-cost diseases, health insurance has a profound bearing on life expectancy because of the increased likelihoods for prevention, early detection and effective treatment.

A Harvard Medical School study, published in the December 26 issue of the Journal of the American Medical Association, found that uninsured people nearing age 65 became ill at a faster rate than those in the same age group with insurance. However, once the uninsured group turned 65 and became eligible for Medicare coverage, the study found, their illness management improved as they gained greater access to care.

Heart attacks and heart failure rates dropped by 10 percent for the newly insured Medicare group between ages 65 to 72, according to Dr. John Ayanian, professor of Health Care Policy and Medicine at Harvard and the study’s lead author.

A second study, published in the January-February issue of CA: A Cancer Journal for Clinicians, authored by researchers at the American Cancer Society (ACS), established the strong association between the lack of adequate health coverage and poor health outcomes for cancer patients. Insured individuals were found to be about twice as likely as those without insurance to have undergone recent mammograms or colorectal cancer screenings. Those with insurance were also more likely to be diagnosed with early stage diseases than the uninsured.

Significantly, analyses of cancer survival statistics from the National Cancer Data Base, a 1,500-facility registry of patient outcomes, revealed that patients who were uninsured and those who were covered by Medicaid at the time they were diagnosed were 1.6 times as likely to die in five years as those covered by private insurance.

The US health-care system is in crisis. More than 47 million Americans went without health insurance for all of 2006, according to the Census Bureau, and the advocacy group Families USA estimates that nearly 90 million people—more than a third of the total population under age 65—were uninsured for at least part of the year.

This indicator has risen steadily over the past few years. As the social safety net is unraveled, access to affordable care decreases, incomes stagnate and the cost of living has risen dramatically.

Since 2000, workers’ earnings have just kept pace with inflation, while insurance premiums have jumped up 98 percent. Declines in employer-sponsored health insurance, coupled with rising premiums, co-payments and deductibles, have also contributed to growing financial burdens for average households.

The direct result is that millions are priced out of health insurance and are unable to secure government coverage. As the cost of treating cancer and other major illnesses rises into the six-figure range, many people are forced into choosing between medical care and other basic needs.

There are many financial pitfalls for households contending with medical problems. Even for those on employer-sponsored coverage plans, a serious illness can result in the loss of insurance through the loss of a job. Those seeking governmental assistance through the Medicaid program are sometimes forced to “spend down” any savings or family worth before qualifying for assistance. And because of continuous eligibility recertifications in the Medicaid program, enrollees are exposed to lapses and losses of coverage; a 2002 federal survey determined that the median Medicaid enrollment for adults under age 65 was a mere five months.

People with lower incomes are much more often uninsured, making them less likely to undergo recommended screenings for common serious and fatal diseases. Once they do seek care, their illnesses are at more advanced and less curable stages. Poor sections of the working class are already at higher risk for cardiovascular disease, diabetes and some types of cancer because of higher rates of smoking, poor nutrition and increased exposure to environmental hazards at their jobs and homes.

According to the ACS study, about 54 percent of uninsured patients between the ages of 18 and 64 included in the cancer database did not have a regular source of health care. About 26 percent delayed their care and nearly 23 percent did not pursue care because of the cost. About 23 percent did not get needed prescription drugs because of the expense.

A 2007 study published in Health Affairs, a health policy journal for the medical industry, found that 37 percent of American adults—and 42 percent with chronic medical conditions—skipped their medications and doctor visits and did not obtain recommended care because of the cost. Approximately one-third of adults in the US had incurred medical expenses of more than $1,000 in the past year.

Nearly a quarter of families living at or below the federal poverty line and 10 percent of those with incomes up to twice the poverty rate bore burdens exceeding 20 percent of family income, according to a 2006 study published in the Journal of the American Medical Association analyzing 2003 Medical Expenditure Panel Surveys data and cited by the ACS. Other research has indicated that about half of all bankruptcy cases list medical care as factors in their filings. The ACS study notes, “Three-fourths of those with medical debt were insured at the onset of the bankrupting illness.”

A separate 2007 Health Affairs study pointed out that the uninsured are charged substantially more by hospitals for care. In 2004, rates charged to “self-pay” and uninsured patients for hospital care were often two-and-a-half times what most insurance companies actually were required to pay, and more than three times the hospital’s Medicare billing allowance.

Uninsured, underinsured and government-insured individuals also faced discrimination by private physicians. The ACS noted that a recent nationwide survey from the National Center for Health Statistics of office-based doctors found that while 96 percent said they were accepting new patients, 40.3 percent would not accept “no charge” patients on a deferred billing or charity basis, 25.5 percent would not accept Medicaid patients and 14 percent refused Medicare patients.

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