In the ongoing healthcare reform debate, one issue seems to hover over the discussion—but is rarely addressed: Is the inability to obtain health insurance associated with a higher probability of death?
A new Harvard University Medical School study brings the topic out into the open by linking nearly 45,000 deaths each year to the lack of health insurance.
The grim new figure is about two and a half times higher than those in a 2002 estimate from the Institute of Medicine, and—if accurate makes a lack of health insurance more deadly than common killers such as kidney disease.
The study found that uninsured, working age Americans have a 40% higher risk of death than their privately insured counterparts, up from a 25% excess death rate found in 1993. Health Insurance and Mortality in U.S. Adults appears in today's online edition of the American Journal of Public Health.
"Limited access to primary or preventative care likely does explain a lot of this," said Andrew Wilper, MD, the lead author of the study, who teaches at the University of Washington Medical School. "We 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."
The study analyzed data from national surveys carried out by the Centers for Disease Control and Prevention. It estimated that lack of health insurance causes 44,789 excess deaths annually. Previous estimates from the IOM and others had put that figure near 18,000. The methods used in the current study were similar to those employed by the IOM in 2002.
Wilper said the study's findings can't be attributed simply to low socioeconomic status. "That is a question we try to answer in the study. We include in our analysis not only income levels but health behaviors, exercise habits, smoking, drinking alcohol."
“No study is perfect," he added, "but we tried to control for those other factors that might be alternate explanations for the findings. All other things being equal, including income, these findings appear to be true."
An increase in the number of uninsured–and an eroding medical safety net for the disadvantaged—likely explain the substantial increase in the number of deaths associated with lack of insurance. Another factor contributing to the widening gap in the risk of death between those who have insurance and those who don't is the improved quality of care for those who can get it.
The research, carried out at the Cambridge Health Alliance and Harvard Medical School, analyzed U.S. adults under age 65 who participated in the annual National Health and Nutrition Examination Surveys between 1986 and 1994. Respondents first answered detailed questions about their socioeconomic status and health and were then examined by physicians. The CDC tracked study participants to see who died by 2000.
"The uninsured have a higher risk of death when compared to the privately insured, even after taking into account socioeconomics, health behaviors and baseline health," Wilper says. "There are always issues in these retrospective studies of whether or not we included all the variables that we could control for. We tried to do that in our study."