Date: May 21, 2002
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FOR IMMEDIATE RELEASE
UNINSURED ADULTS MORE LIKELY TO DIE PREMATURELY
WASHINGTON -- Americans without health insurance are more likely to have poorer health and die prematurely than those with insurance, says a new report from the National Academies' Institute of Medicine. Uninsured patients with colon or breast cancer face up to a 50 percent greater chance of dying than patients with private coverage. Uninsured victims of trauma also are more likely to die from their injuries. Being uninsured for even a year appears to diminish a person's general health.
"Because we don't see many people dying in the streets in this country, we assume that the uninsured manage to get the care they need, but the evidence refutes that assumption," said Mary Sue Coleman, co-chair of the committee that wrote the report, and president, Iowa Health System and University of Iowa, Iowa City. "The fact is that the quality and length of life are distinctly different for insured and uninsured populations."
The committee examined the consequences of being uninsured for people suffering from cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental illness, traumatic injuries, and heart attacks. It focused on the roughly 30 million -- one in seven -- working-age Americans without health insurance. This group does not include the population over 65 that is covered by Medicare or the nearly 10 million children who are uninsured in this country. A future report will look at how the lack of health insurance affects children and pregnant women.
Adults with public coverage, such as Medicaid, are a distinct group as well since they tend to be in significantly worse health than those with private insurance and even in somewhat worse health than those with no insurance. Adults qualify for Medicaid because they are poor or have already incurred unaffordable medical expenses. In addition, low-income adults eligible for Medicaid often do not apply for it until they are sick.
Uninsured cancer patients die sooner than people with insurance do, largely because of delayed diagnosis, the report says. The uninsured are less likely to receive timely screening services such as mammograms, Pap tests, and colon exams. By the time cancer is diagnosed in uninsured patients, it is more likely to be at an advanced, often fatal, stage. Likewise, uninsured patients tend to reach severe renal failure before they begin kidney dialysis.
The longer diabetics go without health insurance, the greater the chance they will experience uncontrolled blood-sugar levels, the report says. Studies show that 25 percent of adult diabetics who were uninsured for a year or more went without a checkup for two years, compared to 5 percent of diabetics with insurance. Uninsured diabetics also are less likely to receive regular foot and eye exams, which can help prevent blindness and amputations.
Uninsured adults with hypertension or high cholesterol are less likely to monitor their blood pressure or stay on drug therapy -- if they are fortunate enough to be screened at all, the report says. Patients admitted to emergency rooms with severe uncontrolled hypertension are more likely to be uninsured.
Uninsured adults with HIV infection or AIDS are less likely to receive the highly effective "drug cocktails" that have become the standard treatment in the past five years, the report says. And when they do get the newer drug therapies, their wait to receive treatment has been an average of four months longer than that of patients with private insurance. Providing health insurance to HIV and AIDS patients has been shown to significantly reduce death rates.
"It wasn't difficult for us to conclude that if the uninsured became insured on a continuous basis, their health would improve and they would live longer," said committee co-chair Arthur Kellermann, professor and chair, department of emergency medicine, and director, Center for Injury Control, Emory University School of Medicine, Atlanta.
Mentally ill patients with insurance that covers their treatment are more likely to receive appropriate care than those with no insurance, the report says. Even when health insurance does not specifically cover mental-health expenses, just having it increases the likelihood that someone with depression or anxiety will receive some care. People with severe mental illnesses such as schizophrenia or bipolar disorder have trouble keeping health insurance coverage after diagnosis because they have difficulty holding down jobs. Until they gain public insurance coverage, these patients face delays in receiving appropriate services.
To see how uninsured patients fare in a hospital setting, the committee focused on two conditions for which most people are treated regardless of whether they are insured: traumatic injuries and heart attacks. It found that uninsured persons with traumatic injuries are less likely to be admitted to the hospital, receive fewer services if they are, and are more likely to die than insured victims. One statewide study of car crash victims discovered that uninsured victims had a 37 percent higher mortality rate. Another statewide study found that although uninsured trauma patients were just as likely to be placed in intensive care, they were less likely to be operated on or to receive physical therapy.
Research also shows that uninsured patients hospitalized for a heart attack have a greater risk of dying during their hospital stay or shortly thereafter than patients with private insurance. They also are less likely to go to a hospital that performs angiography or other catheterization techniques, and even if they do, they are less likely to receive such sophisticated procedures.
Studies that have monitored the health of people who had no insurance or temporarily lost it for a period of one to four years show that a person's overall well-being suffers during the time they lack coverage. The decline in health caused by a lack or loss of coverage is most profound for adults between 55 and 65 years old, the report says. Symptoms of worsening health might include high blood pressure, greater difficulty climbing stairs or walking, or a decline in general self-perceived wellness.
Health insurance strategies that target the entire uninsured population would be more likely to produce greater health benefits and increase life expectancy than "rescue" programs aimed only at the seriously ill, the committee said.
Being uninsured magnifies the health risks for chronically sick and mentally ill patients, as well as for groups that are already at greater risk of poor health, such as racial and ethnic minorities and adults with low incomes, the committee said. It added that increasing health insurance coverage would reduce some, but not all, of the disparities in health care experienced by racial and ethnic minorities.
The committee noted that the research literature on which it based its findings probably understates the differences in health outcomes between insured and uninsured adults. The studies cannot account for the experiences of those who do not seek treatment, and uninsured adults are less likely to seek treatment.
The report is the second of six that will constitute an extensive review of research intended to paint an accurate portrait of who lacks health insurance and why, along with the personal, social, and economic consequences. Rather than add to the many policy recommendations already on the table, the study is designed to lay the groundwork for a more informed and productive public debate about health care coverage. The committee's final report, however, will identify promising strategies for addressing the problems of uninsurance in the United States.
The study is being sponsored by the Robert Wood Johnson Foundation. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.
Copies of CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE
are available from the National Academy Press
; tel. (202) 334-3313 or 1-800-624-6242 or on the Internet at HTTP://WWW.NAP.EDU
. The cost of the report is $27.00 (prepaid) plus shipping charges of $4.50 for the first copy and $.95 for each additional copy. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).
INSTITUTE OF MEDICINE
Board on Health Care Services
COMMITTEE ON THE CONSEQUENCES OF UNINSURANCE
MARY SUE COLEMAN, PH.D.*
Iowa Health System and University of Iowa
ARTHUR L. KELLERMANN, M.D., M.P.H. * (CO-CHAIR)
Professor and Chairman
Department of Emergency Medicine, and
Director, Center for Injury Control
Rollins School of Public Health
Emory University School of Medicine
RONALD M. ANDERSEN, PH.D. *
Fred W. and Pamela K. Wasserman Professor of Health Services and Chair
Department of Health Services, and
Professor of Sociology
School of Public Health
University of California
JOHN Z. AYANIAN, M.D., M.P.P.
Associate Professor of Medicine and Health Care Policy
Department of Health Care Policy
Harvard Medical School
ROBERT J. BLENDON, M.B.A., SC.D. *
Professor of Health Policy and Political Analysis
Department of Health Policy and Management
Harvard School of Public Health and John F. Kennedy School of Government
SHEILA P. DAVIS, B.S.N., M.S.N., PH.D.
Department of Adult Health
School of Nursing
University of Mississippi Medical Center
GEORGE C. EADS, PH.D.
Vice President and Director
Charles River Associates
SANDRA R. HERNÁNDEZ, M.D.
Chief Executive Officer
San Francisco Foundation
WILLARD G. MANNING, PH.D. *
Department of Health Studies
Pritzker School of Medicine and
Harris School of Public Policy
University of Chicago
JAMES J. MONGAN, M.D. *
Massachusetts General Hospital
CHRISTOPHER QUERAM, M.A.
Chief Executive Officer
Employer Health Care Alliance Cooperative
SHOSHANNA SOFAER, DR.P.H.
Robert P. Luciano Professor of Health Care Policy
School of Public Affairs
New York City
STEPHEN J. TREJO, PH.D.
Associate Professor of Economics
Department of Economics
University of Texas
REED V. TUCKSON, M.D. *
Senior Vice President
Consumer Health and Medical Care Advancement
EDWARD H. WAGNER, M.D., M.P.H., F.A.C.P.
W.A. MacColl Institute for Healthcare Innovation
Center for Health Studies
Group Health Cooperative of Puget Sound
LAWRENCE WALLACK, DR.P.H.
Professor of Public Health and Director
School of Community Health
College of Urban and Public Affairs
Portland State University
WILHELMINE MILLER, M.S., PH.D.
DIANNE MILLER WOLMAN, M.G.A.
* Member, Institute of Medicine