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The Price We Pay for Uninsurance

December 2009

Public Citizen Health Letter

In the November issue of Health Letter, we reported the results of a study by our colleagues at Harvard Medical School, published in the American Journal of Public Health, finding that nearly 45,000 deaths a year in the United States are associated with lack of health insurance. At the time of the study, the authors stated that “doctors have many new ways to prevent deaths from hypertension, diabetes and heart disease — but only if patients can get into our offices and afford their medications.”

Since then, three other studies, two by our colleagues Steffie Woolhandler and David Himmelstein and their co-authors, have elaborated on these findings.

The first of these two studies found significant gaps in the care — adequate diagnosis and treatment — for those who are uninsured who have diabetes, high cholesterol or hypertension, leading to an increased risk of costly, disabling and even lethal complications of their disease. The study was based on data collected between 1999 and 2006. The study found that about half of all uninsured people with diabetes (46 percent) or high cholesterol (52 percent) did not know they had these diseases. In contrast, about one-quarter of those with insurance were unaware of their illnesses (23 percent for diabetes, 29.9 percent for high cholesterol).

Under-treatment of disease followed similar patterns, with the uninsured being more likely to be under treated than their insured counterparts: 58.3 percent vs. 51.4 percent had their high blood pressure poorly controlled, and 77.5 percent vs. 60.4 percent had their high cholesterol inadequately treated.

Lead author Dr. Andrew Wilper, who worked at Harvard when the study was done and who now teaches at the University of Washington Medical School, said:

Our study should lay to rest the myth that the uninsured can get the care they need. Millions have serious chronic conditions and don’t even know it. And they’re not getting care that would prevent strokes, heart attacks, amputations and kidney failure.

According to Dr. David Himmelstein, associate professor of medicine at Harvard and study co-author:

The Senate Finance Committee’s bill would leave 25 million Americans uninsured and unable to get the ongoing, routine care that could save their lives and prevent disability. No other wealthy nation tolerates this, yet Congress is turning its back on tens of millions of Americans.

The second study updated previous estimates of the toll of the lack of insurance on veterans in the U.S., many of whom lack health coverage.

The Harvard researchers say 1.46 million working-age vets lacked health coverage last year, increasing their death rate. The research team estimates 2,266 U.S. military veterans under the age of 65 died last year because they lacked health insurance and thus had reduced access to care. That figure is more than 14 times the number of deaths (155) suffered by U.S. troops in Afghanistan in 2008, and more than twice as many as have died (911 as of Oct. 31) since the war began in 2001.

Using their recently published findings in the American Journal of Public Health that show being uninsured raises an individual’s odds of dying by 40 percent (causing 44,798 deaths in the United States annually among those aged 17 to 64), they arrived at their estimate of 2,266 preventable deaths of non-elderly veterans in 2008.

“Like other uninsured Americans, most uninsured vets are working people — too poor to afford private coverage but not poor enough to qualify for Medicaid or means-tested VA care,” said Dr. Steffie Woolhandler, a professor at Harvard Medical School who testified before Congress about uninsured veterans in 2007.

Dr. David Himmelstein, the co-author of the analysis and associate professor of medicine at Harvard, commented, “On this Veterans Day we should not only honor the nearly 500 soldiers who have died this year in Iraq and Afghanistan, but also the more than 2,200 veterans who were killed by our broken health insurance system. That’s six preventable deaths a day.”

The third study, done by other researchers at Harvard Medical School, was based on the idea that because of “pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist.”

Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006. The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges.

The authors measured in-hospital deaths after blunt or penetrating traumatic injuries. They found that uninsured patients with traumatic injuries, from car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance.

Treatment delay, different care (via receipt of fewer diagnostic tests) and decreased health literacy were proposed as possible mechanisms whereby uninsured trauma victims were more likely to die from their injuries.

“This is another drop in a sea of evidence that the uninsured fare much worse in their health in the United States,” said senior author Dr. Atul Gawande, a Harvard surgeon and medical journalist. The study appeared in the November issue of the Archives of Surgery.

Taken altogether, these studies are elaborating important details of how and why 45,000 Americans die each year related to their lack of health insurance. That this occurs in a country that spends more — $2.5 trillion a year on health care — than any other so-called developed country is unacceptable. As long as we continue to tolerate a private, for-profit health insurance industry that provides the mechanisms for excluding upwards of 50 million people from having health insurance, these grim realities will continue. A system in which everyone is in and nobody out means eliminating the private health insurance industry.

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