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Does Lack Of Insurance Cause Premature Death?

September 21st, 2009

Truth is not only the first casualty of war, it is also the first casualty of serious public policy debate.

Last year, a report by Families USA made the astounding claim that 6 people die every day in Florida because they are uninsured. Seven die every day in Texas, 8 in California, and 25 in New York.

How was Families USA able to tally up all that carnage with such pinpoint precision? As Linda Gorman explains, these claims are based on a 15-year cascade of studies — each repeating the errors and misinterpreting or mischaracterizing the findings of the previous one and ultimately relying on data that is 37 years old.

It begins with a paper by Peter Franks et al. published in the Journal of the American Medical Association in 1993, estimating that being uninsured increased the probability of death by 25%. Although the subjects were interviewed only once, for the study’s inference to be meaningful, one is forced to make the unverified assumption that the uninsured stayed uninsured for a full 19 years!

Continuing the saga, the Institute of Medicine (IOM) uncritically used the Franks result to claim that 18,000 deaths a year in the U.S. are attributable to a lack of health insurance. The Urban Institute updated the IOM report, and Families USA updated the Urban Institute report.

Physicians for a National Health Program Produces The Latest In A String Of Flawed Studies

Not to be outdone, Physicians for a National Health Program (PNHP) has just repeated the exercise (with all its methodological sins) and boosted the tally to a 40% increase in the probability of dying for the uninsured. That produces a whopping 45,000 premature deaths every year — almost as bad as the Vietnam War. And, yes, we get a state-by-state breakdown. There will be 5,302 deaths attributed to uninsurance in California this year. There will be 75 in Wyoming, etc., etc. There is even a minute-by-minute tally: “The Institute of Medicine, using older studies, estimated that one American dies every 30 minutes from lack of health insurance,” says David Himmelstein, one of the authors. “Now one dies every 12 minutes.”

As in the previous incarnations, the researchers interviewed the uninsured only once — and never saw them again. A decade later, the researchers assumed the participants were still uninsured and, if they died in the interim, lack of insurance was blamed as one of the causes.

Yet, like unemployment, uninsurance happens to many people for short periods of time. Most people who are uninsured regain insurance within one year. The authors of the PNHP study did not track what happened to the insurance status of the subjects over the decade examined, what medical care they received or even the causes of their deaths.

Also, before you go into mourning too quickly, be aware that when former Director of the Congressional Budget Office (CBO) June O’Neill and her husband Dave used a similar approach, they found that the involuntarily uninsured (low-income people) were only 3% more likely to die over a 14-year period than those with health insurance. There was no statistically significant effect on the “voluntarily uninsured” (higher-income people).

That’s not too surprising in light of a RAND study finding: Although people are receiving appropriate care a little better than half the time when they see doctors, the care they receive is not affected by whether they are insured or by the type of insurance they have. People who are uninsured, of course, may delay seeing a doctor in the first place — because of their lack of insurance. But this problem is unlikely to be solved by enrolling them in Medicaid programs that routinely ration by waiting.

The uninsured in the PNHP study are disproportionally poor, minority, high school dropouts and unemployed. Although the study ignores public insurance, bills before Congress would try to insure this group by expanding Medicaid. The O’Neills found that people enrolled in Medicaid have a much higher mortality rate than the uninsured. In other words, Medicaid enrollment reduces life expectancy rather than increasing it!

Even more odd, the PNHP authors are on record as favoring Canada’s system of single-payer national health insurance. Yet insured patients in Canada fare worse than the uninsured in the United States. The O’Neills found that:

• Among US women age 40 to 64, 87% of those with insurance had a mammogram within 5 years.
• The rate for Canadian women was 65% — the same as for uninsured women in the US.
• Canadian women also had the same rate of screening for cervical cancer as uninsured US women (80%), over five years. Among insured US women, the rate was 92%.
• Among uninsured US men, 31% were screened for prostate cancer, compared with 16% of Canadian men. For insured US men, the rate was 52%.

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7 Trackbacks for “Does Lack Of Insurance Cause Premature Death?”

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9 Responses to “Does Lack Of Insurance Cause Premature Death?”

  1. THarmony89 Says:

    Excellent post. It’s crazy to think that those numbers are correct and it also makes ya think what would happen if everyone was uninsured??


  2. Mlynn Says:

    Great post. It’s amazing to me that these studies can get away with such obvious holes in their research. Thanks for shedding further light on the issue!

  3. Barbara Starfield Says:

    John Goodman’s blog, complaining about serious errors in many studies, commited some of his own. Arguing that things are better in the US than in Canada, he cites data on the performance of procedures, not achievement of health. On almost every measure of health, Canadians do better—-even after taking into account SES and race—-and on some measures of health, considerably better. There are also some excellent studies of the superiority of the Canadian system in dealing with inequities in breast cancer mortality.

    Barbara Starfield

  4. RMcCullough Says:

    Thanks for posting this. It looks like Dr. Goodman is exposing junk service.

  5. johnrgraham Says:

    The article is a little opaque, so I might have this wrong, but the authors estimated 35,327 deaths associated with lack of health insurance when considering all Americans aged between 18-14. However, when they estimated without “age stratification”, they estimated 44,789.

    Table 1 segments the sample by age: the younger groups are more likely to be uninsured than the older ones (29% for those aged 17-24 versus 9% for those aged 55-64). They are also less likely to have died at the end of the period (1% for those aged 17-24 and 11% for those aged 55-64).

    So, if the model assumes (utterly unrealistically) that lack of health insurance at the initial interview persists, and adjusts the death rate as the sample ages, the more accurate conclusion is that aging is related to increased likelihood of death!

  6. johnrgraham Says:

    Ever since the 18,000 figure came out I was surprised to see that nobody pointed out that over 2 million people die in the U.S. every year, so ascribing statistical significance to an estimate much less than one percent of the total is pretty risky. You’d need a more powerful model than I could design!

  7. Brian R Williams Says:

    Good post.

    Forgive me for asking: If being uninsured increases my probability of dying, does the same premise hold true for all types of insurance? Am I more likely to crash my car if I don’t have auto insurance? Is my house more likely to catch on fire without homeowner’s insurance?

    I suspect modern health insurance has become a way to pre-pay for health care instead of insuring against risk. I pay premiums in advance so an insurance company will pay my medical bills for me when I get sick. No wonder the system is messed up.

  8. SauerC Says:

    Great Post!

    Studies like these from Families USA and PNHP are frustrating. Not only does “insurance” not equal “access”, but they don’t even attempt to correctly identify the uninsured.

    The truth might be the first to go, but it is important that it keeps being published.


  9. pfafard Says:

    Interesting argument.

    As for the comparison between the insured in Canada and the uninsured in the United States, the data presented and the conclusions drawn from the data seem to assume that the only variable that matters is having insurance coverage. Yet we know that whether or not a woman has a mammogram or a man is screened for protate cancer will depend, among other things, on the advice of their physician and overarching guidelines as to when and who should be screened. In other words, variance between Canada and the U.S. may be due to things other than insurance coverage.

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