NEWS

For the Uninsured, Health Problems Are More Serious

Charles Marwick

In the management of diseases such as cancer, just providing adequate health insurance could make a greater impact on health than many publicized improvements in clinical procedures such as surgery or chemotherapy. This is one of the principal messages of a new report from the Institute of Medicine.

For example, uninsured patients with breast cancer have a 30% to 50% greater chance of dying than patients with private insurance coverage. Uninsured patients with colon cancer have a 50% to 60% higher mortality rate than those with private insurance. A similar situation prevails with trauma patients. The report found a 37% higher mortality rate among uninsured accident victims than among those who were privately insured.

In plain numbers, lack of health insurance may account for some 18,000 premature deaths annually. Among the leaders: 600 women with breast cancer, 1,400 people with high blood pressure, and 1,500 people with HIV infections may die prematurely because they lack health insurance.

"These are staggering statistics and are, quite frankly, alarming," said Reed Tuckson, M.D., senior vice president, United Health Group, Minneapolis, Minn., and a member of the committee drafting the report, "Care Without Coverage: Too Little, Too Late," which is the second of six reports the Institute of Medicine is preparing with support from the Robert Wood Johnson Foundation. The reports constitute an extensive review of who lacks health insurance and its effect on health. The first report appeared in October 2001.

In one sense, the report’s findings confirm what most people have assumed: It’s better to have health insurance than not. But what surprised the committee was the pervasiveness of the effects of not having insurance. Arthur L. Kellerman, M.D., director of injury control at the Rollins School of Public Health, Emory University School of Medicine, Atlanta, and co-chair of the committee, enlarged on the point in an interview.

"We, on the committee, were aware of individual publications that point to an association between being uninsured and having poor health outcomes," he said. "But what we did not expect was the volume of information, the consistency of that information, and the magnitude of the effect. It was evident across a range of health conditions, a range of issues involving preventive care, primary care, and the management of chronic diseases such as cancer."

Comprehensive Review

The report is based on findings from a critical and comprehensive review of some 130 studies published in the past 20 years on the association between health insurance status and adult health. It focuses on the roughly 30 million Americans between the ages of 18 and 65 years of age who lack health insurance. "It was compelling evidence of poor health status and premature death," Kellerman said. "This report makes the case more strongly than anything to date."

A third report, to be published in September, will examine the health consequences for children, pregnant women, and families and will look into the economic consequences that come with the lack of health coverage.

Besides cancer and traumatic injuries, the committee looked into lack of health insurance and outcomes of patients with diabetes, hypertension, heart and kidney disease, mental illness, and HIV infection and AIDS. In all of these conditions, whether the patient received timely and adequate care depended on whether they had health insurance.

For example, uninsured patients with high blood pressure have diminished access to care, are less likely to be screened, less likely to take prescription drugs if they are diagnosed, and have worse clinical outcomes than people with high blood pressure who have health insurance, said Mary Sue Coleman, Ph.D., co-chair of the committee, president of the Iowa Health System at the University of Iowa, and the president-elect of the University of Michigan.

Likewise, uninsured adults with HIV infection are less likely to receive the highly effective medications that have been shown to improve survival. Health insurance reduces the risk of death in the short term among HIV patients by as much as 85%. Similarly, patients with mental health conditions including depression, anxiety disorder, or severe mental illnesses such as schizophrenia or bipolar disorder are more likely to receive care for their condition if they have insurance that covers mental health services.

Uninsured adult patients are hospitalized less frequently than those who have some kind of health insurance. When uninsured patients do receive care in the hospital they have higher in-hospital mortality rates, receive fewer services, and are more likely to experience poor quality care than patients with insurance.

In short, health insurance and health outcomes are intimately linked. "If those adults who are not currently insured were covered on a continuous basis, their health could be expected to be better and their risk of dying prematurely would be reduced," said Coleman. "But the benefits to health of insurance coverage can be achieved in full only when the health insurance is acquired well before the development of advanced disease. For example, the problem of later diagnosis and higher mortality among uninsured women with breast cancer cannot be solved by insurance that becomes available only when the diagnosis is made."

Goal of the Reports

The aim of these reports is to provide "the most trusted judgment about what research and empirical studies have to say about the benefits and costs of health insurance coverage," said Wilhelmine Miller, Ph.D., the committee’s study director. "The goal is to produce documentation and findings about the implications of maintaining an uninsured population and to develop some very broad policy principles and guidelines." The reports are not a plan for health insurance reform; rather, it is to outline the best strategies for providing health insurance, according to Kenneth Shine, M.D., retiring IOM president.

In the process, the committee is clearing away some of the misconceptions about health insurance. One pervasive myth, Kellerman said, is that the uninsured get the care they need, so there really isn’t a problem. "We have shown very clearly that this is not the case. In order to make decisions about what we should do we have to start with a clear understanding of the price that’s being paid by failing to come to grips with this issue, whatever strategies are ultimately adopted or implemented. The committee is laying the groundwork for a real discussion of the issue of health insurance," he said.

"There are very real and measurable costs associated with this non-system," Kellerman pointed out. "We hope that in the end these reports will be a coherent and compelling portrayal of the consequences of un-insurance, not only for policy makers but also for the nation at large. Ultimately," he noted, "this is not merely an issue of what happens to the roughly 40 million Americans who don’t have health insurance, but it has implications for 280 million Americans—for society at large. If society is in poor health, it can’t function."



             
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