Do the uninsured die sooner than the rest of us becaue they don’t have access to medical care—or because more than three-quarters of the uninsured are poor? In part 1 of this post, I explained that we know that poverty is a killer. It destroys mind and body, slowly but surely. In the U.S. the poor die seven years earlier than the rich.
I also explained that lack of access to medical care is not a major factor in determining who dies prematurely. Social circumstances, personal behaviors, and environment account for 60% of early deaths, and each is closely tied to socio-economic status.
Most Americans assume that good health care is the key to longevity. But in 2002 the Kaiser Family Foundation published a study that poses a radical question, “Does having health insurance improve your health?“ It might sound like a foolish query. One wants to say “Of course!”
But early in the report, the authors acknowledge that “there is no definitive research that unambiguously answers this question, one way or the other.”
Are We Over-Estimating the Importance of Medical Care on the Margin?
They explain why: “An ideal study designed to answer it would randomly assign a representative sample of people to insured (treatment) and uninsured (control) groups. People in the treatment group would presumably use more medical care than people in the control group because having insurance lowers the cost of care.
“The extra services used by the insured might be a mix of more preventive care, more screening and diagnostic care designed to detect disease at an early, more treatable phase, and more aggressive treatment of illness when it occurs. Some people without insurance would find such treatments unaffordable and choose to forego care. If these are the effects of having insurance, then we might very well expect the insured group to have better health after some period of time.
“But,” the report continues, “Suppose instead that the extra care received by the insured group was primarily medical services that were unneeded and provided little clinical benefit. . . . Suppose also that people without insurance are generally able to get care when they really need it . . . .”
In other words, while the uninsured do not receive the chronic disease management that they need, when they become seriously ill, they wind up in an emergency room where, most of the time, they are rescued.
When researchers try to investigate the benefit of having insurance and easy access to medical care, they run into another complication: if you look at the affect of additional medical care on healthy, well-insured peopled you find little or no benefit. For example, while the well-known RAND Health Insurance Experiment showed that low or no co-pays increases the amount of medical care people consume, “for the average person there were no substantial benefits from free care."
However, as the authors of the Kaiser study point out, the problem of being uninsured is not, by and large, a problem for “the average American – it is primarily a problem for low-income people.” And precisely because low-income people are sicker than average, they need more medical care.
The authors of the Kaiser report conclude: “Even if one accepts as valid the findings of the more methodologically sound studies that suggest little or no health benefit from additional medical care use by well-insured populations, it does not necessarily follow that the uninsured would not benefit both from health insurance coverage and from greater medical care use. Holding both points of view would not be inconsistent. In fact, it would seem to be both inappropriate and unfair to argue on the basis of these studies that the uninsured should be penalized, i.e., denied help in obtaining insurance coverage, because of the inefficient or excessive use of medical care by the well insured.
“Even if the marginal benefit [of more care] to the average, relatively healthy, privately insured person is close to zero, it does not follow that the benefit is also zero for a poor patient.”
The Uninsured Are More Likely to Die of Specific Diseases—But Why?
Studies of outcomes from specific diseases (breast cancer, colorectal cancer, cardiovascular disease, and trauma) reveal that the odds of dying within a particular time period were from about 1.2 to 2.1 times greater for an uninsured person with the particular condition compared to a privately insured person. We also know that the uninsured tend to be diagnosed later.
But reserachers still can’t answer the question of causality: Do tens of thousands of uninsured people die because they weren’t diagnosed in time? Or did they die because they were poor as well as uninsured—and thus not as strong as more affluent patients who managed to survive a heart attack or cancer?
In the end, studies linking the lack of insurance to mortality are inconclusive. “These studies vary in how they report their results, some as relative odds, some as relative risk ratios, and others as elasticities,” the authors of the Kaiser study acknowledge. Taking these differences into account, their estimates of the quantitative effect of extending health insurance coverage to all suggest that “the mortality rates of the uninsured would decline by at least 5% and, depending on age and medical condition, by as much as 20-25%, with some studies suggesting that the reduction could be as high as 50%.”
In essence, they are saying that “while we are quite certain that access to care must benefit patients, we have absolutely no idea how large that benefit is.”
The Wrong Question
Ultimately, when people ask “how many lives would be saved if we all had insurance?” I think they are posing the wrong question.
A better question would be: “how many people suffer needlessly because they don’t have access to care?
Why should “mortalities” be the measure of how much good health insurance –or medicine itself– can do? Health care will not rescue us from the human condition. And as I explained in part 1, evidence shows that access to medical care is not the major factor that guards against premature death. Genes, social circumstances and personal behavior all are far more important.
Despite our national obsession with longevity, and our belief that hi-tech medicine will rescue us, the truth is that very often, modern medicine cannot cure us—but it can provide comfort and care. This is why health insurance is important.
Whether the patient is a child with an ear-ache, a 60-year-old who should have a knee replacement, or a chronically depressed 40-year-old, good insurance can open the door to the help the poor need. In a life-threatening situation, the uninsured may well get the emergency care that they require. But most medicine isn't about saving lives, it's about enhance the quality of life. This is why everyone deserves health insurance.
Richard Kronick agrees. In part 1 of this post, I explained that when he adjusted for demographic differences Kronick finds no evidence that an uninsured smoker dies sooner than a smoker who is insured. But he explained to Politifact.com, “I don't doubt that the individual's' health suffers when they're uninsured.” “No one would choose not to have insurance if they could afford it," Kronick added, "There's no benefit to having 47 million Americans uninsured."
Yet there is a limit to what insurance can do. It cannot create jobs. Or safe playgrounds. Or urban farms on inner-city roofs. It cannot reduce class sizes in our public schools. It cannot build pre-schools.
If we are interested in reducing the level of premature deaths in this country, we must invest in public health. This means focusing on the poor.
As Schroeder pointed out a the end of the 2007 Shattuck lecture: “To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health. . .It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes.
In other words, we focus on treatments for individuals suffering from acute illnesses, but in this country, public health is considered medicine's poor cousin. We have plenty of heart clinics where a well-insured person suffering from chronic chest pain can get an aingioplaty–even though, as the Wall Street Journal pointed out not long ago, using stents to unclog artieries " usually yields no additoinal benefits" over giving the patient "a cocktail of generic drugs".(Hat tip to Gary Schwitzer for pointing to this story on his Health New Reveiw Blog But we have retlatively few smoking cessation clinics where a person can get a free nicotine patch. (Even if a smoker has insurance, it raretly covers smoking cessation because insurers do not want to attract customers who smoke. .)
Meanwhile few lobbyists represent the poor: “the disadvantaged are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties" Schroeder writes. " Without a strong voice from Americans of low socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses, such as breast cancer, human immunodeficiency virus infection and the acquired immunodeficiency syndrome (HIV–AIDS), and autism. These efforts are led by middle-class advocates whose lives have been touched by the disease. There have been a few successful public advocacy campaigns on issues of population health — efforts to ban exposure to secondhand smoke or to curtail drunk driving — but such efforts are relatively uncommon. Because the biggest gains in population health will come from attention to the less well off, little is likely to change unless they have a political voice and use it to argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental threats. . ."
In addition, "the American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choices.”
Yes, without question, we need health care reform. But we shouldn't kid ourselves about what reform will do. Neither Aetna nor a single-payer system will save tens of thousands of lives. To do that, we need a war on poverty.
In the end, Schroeder suggests that in “the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for population health.. . . Americans take great pride in asserting that we are number one in terms of wealth, number of Nobel Prizes, and military strength. Why don't we try to become number one in health?”
When we argue that poor people suffer because they lack health insurance, too many people don’t care. It’s their fault and the poor are a big drain on taxpayers (say the angry white men). The more important group to focus on are hardworking Americans who have lost insurance or are self-employed and can’t get or can’t afford health insurance. I think there is more sympathy out there for these people. These are people who have played by the rules and taken care of themselves and are now one medical crisis away from financial ruin. As an insurance agent I have met too many people in this situation and I’m wondering why there isn’t a tea party, angry, protest group demanding protection for these hardworking taxpayers.
I agree, Maggie, with your emphasis on the multiplicity of factors involved in premature mortality, and the need to address all of them. Many of them are intertwined, and so one can’t say, “It isn’t A, it’s B”.
The insurance/mortality relationship is complex, and as you point out, the quantitation is inexact and controversial. I find it hard to conceive how, ceteris paribus, lack of insurance would fail to contribute to excess mortality, and the comparisons with other universally insured nations bears this out. Some suffer from less obesity but more smoking-related illness, and no nation exhibits exactly the same risk factors as another, but we are too divergent from the pack to attribute all differences to bad habits. I certainly agree with your assessment of the role of poverty, but I think that bad habits and poverty alone do not tell the entire story.
I’ve read both the Kronick article and the one by Wilper et al (up to 45,000 excess deaths annually due to lack of insurance). The 45,000 figure may be too high, but it’s only about 1 percent of total U.S. mortality, so it shouldn’t be dismissed out of hand. Although not an epidemiologist, I judged the Kronick study to have overcorrected for some confounding variables in a way that inappropriately tends to equalize insured and uninsured populations. The Kronick and Wilper studies claim to be looking at the same problem with similar methods, and so it’s hard to judge which is closer to the truth. I suspect the real figure is somewhere in between, which still may amount to more than 10,000 lives per year. As you state, premature death alone is hardly the only type of misfortune we want to avert, and so concern for the preservation of health and overall well-being rather than merely longevity should remain a goal.
It’s important, when issues of casuality are debated, to avoid the trap of dodging responsibility for acting on one potential cause simply because there are others, or because we’re not yet sure. As you quote Kronick as saying, “There’s no benefit to having 47 million Americans uninsured”. The burden of proof rests on anyone who would argue otherwise.
Here’s an idea… High schools require math and science and English in most every year, right? So why not require health, fitness and nutrition courses in each year of high school too? OR, why don’t elementary schools drop the traditional P.E. time (if they haven’t done so already) in favor of TEACHING fitness and nutrition? P.E. was good exercise, but never did it teach me anything about the importance of fitness. Why not spent a chunk of that time pounding fitness and nutrition info into the heads of young kids so they can develop good habits at a young age? I didn’t get my first health class until my junior year of high school, and even then it was only a single semester (the other semester was driver’s training) and it focused mostly on contraception–a good cause in itself. I understand that good habits start AT HOME, but that idea simply isn’t working anymore, so, like it or not, it’s up to the schools to make a dent in problem. I think having a course in high school each year in nutrition/fitness INSTEAD of P.E. would make a massive difference. Teach kids WHY they should exercise instead of telling them “run around the track 4 times then head to the locker room.” That’s like forcing broccoli down a kid’s throat instead of teaching them why they need veggies in the first place–it helps in the short-term, but doesn’t set a lifelong standard.
The basis upon which a lot of the legislation in front of lawmakers is up for question. What is our aim in providing hc to everyone in the country. Something to think about.
Regarding my earlier comment, I have reread the Kronick article. Kronick appropriately acknowledges that the mortality ratio between unninsured and insured will vary depending on which variables are corrected for. His conclusion of no significant difference (3 % higher among the uninsured) is, as he notes, dependent on adjusting for self-reported health status at the start of the observed interval. However, if uninsured individuals are unhealthier to start with compared with insured individuals, after correction for other variables (income, age, education, etc.), and if much of that difference is due to the lack of insurance (again, I repeat, after adjusting for income, etc.), then the increased risk rises to approach 10 percent. I don’t know whether insurance has a causal effect on smoking cessation, but such an effect could result in a risk due to insurance lack exceeding 10 percent (up to 20 percent if smoking were entirely amenable to correction by insurance, which is almost certainly not the case). In summary, a figure of about 10,000 excess deaths annually causally related to insurance lack, while speculative, is plausible consistent with the data in the Kronick study.
Solid analysis of why we need better access to health care.
The next question should be why why 10-12 million uninsureds are if fact eligible for Medicaid TODAY. Massachusetts found that nearly half of their uninsureds were Medicaid eligible! Reasons range from states that make it difficult to enroll, people don’t know, and the saddest answer that some are just too lazy. States make it difficult to enroll because it is expensive. Good time to assess a program that was long ago designed to address the above but now viewed by many states as unaffordable.
Next question is what to offer the illegal aliens that are uninsured. No easy answers here, but we could have a very spirited debate on both creating an affordable Medicaid program and illegal immigration before blowing up the existing system.
An incremental approach could get a lot of people insured – and healthier!
President Obama announce the health program is not so good like former Precident. Republicans have been fairly quiet about their own grand vision for the future of health care.What about poor people?
Fred,
Thanks for another insightful comment.
But in this case, I don’t’ entirely agree.
I’d urge you to read Schroeder’s Shattuck lecture and also the Gittleson et. al. research that he fnotes.
In my mind, this is the bottomline: : Poverty is a much bigger problem than lack of health insurance–it affects many more people.
A new study from the Brookings Institution reveals that from 2000 to 2008, the number of poor people in the U.S. grew by 5.2 million, reaching nearly 40 million. That represented an increase of 15.4 percent in the poor population, which was more than twice the increase in the population as a whole during that period.
New York Times columnist Bob Herbert adds: “The study does not include data from 2009, when so many millions of families were just hammered by the recession. So the reality is worse than the Brookings figures would indicate.”
By 2008 Herbert reports, a startling 91.6 million people — more than 30 percent of the entire U.S. population — “were living below 200 percent of the federal poverty line, which is a meager $21,834 for a family of four.”
30 percent of all Americans living on less than $21,834 for a family of four. . . .
The toll that poverty takes on their psychological and physical health is much greater than just the lack of health insurance.
Thus 30 percent of all Americans die 7 years sooner than wealthy Americans—because they are poor.
How many lives would be saved if they had health insurance? Probably many fewer than you suggest
Keep in mind that people who have access to medical care are sometimes harmed by it. “Iatrogenic diseases s” (disease inadvertently caused by medical care) is a huge problem. More people die of complications following surgery than die in car accidents in the U.S. each year. And, as ATul Gawande points out, many of these patients didn’t need surgery in the first place.
The uninsured are much less likely to be exposed to unnecessary surgeries, hospitalizations, tests that lead to unnecessary treatments, etc.
AS for whether being insured makes it easier to quit smoking– As this article from Managed Care points out, most employer-based insurance does NOT cover smoking cessation programs. See http://www.managedcaremag.com/archives/0105/0105.peer_smoking.pdf
If you smoke, the article points out, insurers would rather raise your premiums than pay for smoking cessation medications, clinics, etc.
Also, they are afraid that if they offer smoking cessation coverage, they will attract customers who smoke!
Denise–
A great many poor people also work very hard, and play by the rules.
But if you have the bad luck, as an infant, to be born into poverty, your chances of getting out of that situation are very small.
Forty or fifty years ago, there was much more
social mobility in this country– which means that someone who was born poor had a fair chance of moving up the economic ladder.
That is no longer true. (For evidence, just Google “social mobility” and “2009” and you will find much research on this topic.)
I am also very sympathetic to middle-class Americans who have lost their jobs.
But this is not an either/or choice. Middle-class Americans who have lost their jobs need help,and people living in
poverty need help.
Hi Maggie – Thanks for responding to my comment. I believe we agree more than disagree. You state:
“Poverty is a much bigger problem than lack of health insurance–it affects many more people.
A new study from the Brookings Institution reveals that from 2000 to 2008, the number of poor people in the U.S. grew by 5.2 million, reaching nearly 40 million.”
Although that doesn’t exceed the number of uninsured, I think your judgment that poverty is a more significant cause of premature mortality is undoubtedly correct.
You further state:
“30 percent of all Americans die 7 years sooner than wealthy Americans—because they are poor”.
This certainly would substantiate the dominant role of poverty. However, I still judge the evidence to be compelling regarding the relationship between lack of insurance and excess mortality. All studies examining this relationship correct for income and then estimate the role of insurance lack after that correction is made. On one end is the Wilper et al study estimating an excess of up to 45,000 deaths annually. On the low end is the Kronick study that, at current uninsurance levels, would be consistent with about 3000 excess deaths, and without overcorrection for initial health status, would imply about 10,000 excess deaths annually. That figure of 10,000 is well below the excess that would result from poverty, but is nevertheless not inconsequential.
The conclusion I draw is that implementation of current proposals to cover the uninsured would save many lives, and that, independently, the need to address poverty and income inequality in American society should continue to be one of our most urgent priorities.
Fred–
Yes, we need both universal coverage and
a war against poverty.
Certainly, health insurance saves some people from dying. I just think that the number that some health care reformers cite exaggerate what health care can do-while ignoring the effects of poverty.
But, as I emphasize in part 2 of this post, even if access to healthcare can’t save tens of thousands of lives (poor people will die earlier anyway) it can address needless suffering and enhance quality of life.
No question: everyone should have access to health care.
I would just like to see us give equal attention to public health, and launch that war on poverty.
Robert–
I agree that we shoudl teach kids about health and nutrition.
When I was in high school that was part of our biology class.
But I definitely don’t think that we should repalce PE with health & nutrition.
For many kids, PE three times a week may be the most exercise they get.
And, one hopes, it gives them enough exercise to make them able to play sports, etc.
I’d add that I think we could teach health and nutrition to much younger kids–i.e. 6th graders.
In sixth grade much time is spent on pointless topics–looking up unimportant facts on the INternet, etc.
Maybe kids could read about nutrition on the Internet, and write reports about what they read???