State-by-state analysis ties lack of insurance to earlier death

Washington -- Uninsured people die prematurely at a rate that equals several additional deaths per day in highly populated states, such as Texas, Florida and California, according to recent analyses by the consumer group Families USA.

The reports, released in March and April, are based on earlier studies by the Institute of Medicine and the Urban Institute, a policy research organization. Overall, uninsured people between the ages of 25 and 64 were 25% more likely to die than their same-aged insured counterparts, concluded the 2002 Institute of Medicine report from 2000 data. This increased mortality equaled an additional 18,000 deaths in 2000. The Urban Institute found that lack of insurance caused 22,000 adults' deaths in 2006.

The Families USA analysis, "Dying for Coverage," used the two organizations' methodologies to develop state-specific mortality rates for the uninsured. For example, the estimated number of uninsured adults between 25 and 64 years old in Texas who died prematurely between 2000 and 2006 was nearly 17,700, or more than seven each day, the report said.

"Health insurance really matters in how people make their health care decisions," said Ron Pollack, executive director of Families USA. "We know that people without insurance often forgo checkups, screenings and other preventive care."

But one can't conclude that being uninsured alone killed people, said Kim Bailey, Families USA senior health policy analyst. Instead, not having health insurance is associated with mortality-increasing behavior. "We can't actually attribute any individual deaths," Bailey said.

Still, lack of insurance can hasten death, said AMA President-elect Nancy H. Nielsen, MD, PhD. The death of one uninsured woman in her 50s sticks in her mind. A few years ago, a former student of Dr. Nielsen invited her to speak at a Cleveland hospital. As part of the invitation, Dr. Nielsen was given an old case to diagnose in front of an audience: A woman in her 50s without health insurance who was experiencing abdominal pain.

After hearing several minutes of background on the patient, Dr. Nielsen eventually asked when the woman's last Pap smear was. The answer: 10 years ago. The woman had developed uterine cancer, a curable disease if caught early. She died a few months after the initial diagnosis.

"You can dance around it all you want, but people who do not have health insurance delay the kinds of preventive care that everybody acknowledges are critical," Dr. Nielsen said. "That woman had a preventable, curable disease, and as a society we failed her because we have not made affordable health care available to all Americans."

The AMA's proposal to expand access to health insurance calls for providing tax credits or vouchers to individuals and families, based on income, to help them buy health insurance. The plan also includes expansion of health plan choices, more unified regulation of health insurance, guaranteed policy renewals, an individual insurance mandate for those earning more than 500% of the federal poverty level, and subsidies for high-risk enrollees.

But even people with health insurance die prematurely, noted Timothy Gorski, MD, an ob-gyn in Arlington, Texas. He said the premise that being uninsured leads to premature deaths is "plausible." But "there's lots and lots and lots of reasons why people don't get preventive care that could save their lives."

For example, depression leads people to delay or forgo care, as does fear of colonoscopies and other uncomfortable preventive procedures. Also, sometimes people would rather spend money on things other than health care, Dr. Gorski said.