Does Lack of Health Insurance Kill?

The results from the Oregon Experiment, published in the New England Journal of Medicine on May 2, show that extending Medicaid to low-income adults did not improve basic clinical measures of health. Given that, it is a bit hard to see how being uninsured can cause 45,000 premature deaths every year — a figure rivaling the number of Americans killed in the Vietnam War. That’s the number physicians for a National Health Program say die prematurely in America due to a lack of health insurance.

The Oregon study results probably did not surprise those who have been paying attention to the serious academic literature, however. In independent empirical papers, Richard Kronick and David Card and his colleagues find little evidence that health insurance coverage significantly reduces mortality. Former Director of the Congressional Budget Office June O’Neill and her husband Dave also conclude that lack of insurance has little or no impact on mortality. See the discussion at this blog here, here and here.

One person who ordinarily pays scrupulous attention to the quality of research is Austin Frakt. Yet in a surprisingly irate blog post he makes this claim: the fact that health insurance improves health and reduces “mortality risk” is “well established” and “as close to an incontrovertible truth as one can find in social science.”

In another post he asserts that Megan McArdle “distorts the scientific record” in an Atlantic article in which she concluded that there was little evidence to support the claim that people die because they do not have health insurance. He accused her of cherry picking, of “misrepresent[ing] a body of work in support of that conclusion and further mislead[ing] readers that such work does not exist.”

Professor Frakt owes Ms. McArdle an apology.

Let’s look at the references that Professor Frakt uses to support his claim. He refers readers to a number of links. They include an article by Stan Dorn of the Urban Institute on Ezra Klein’s blog; an article in the New Republic by Harold Pollack, a professor of Social Service Administration at the University of Chicago; and a blog post by J. Michael McWilliams, assistant professor of health care policy and medicine at Harvard Medical School. Each of these articles cites other articles. They add up to an impressive total, but a number of them shed very little light on the question at hand.

The citations rely heavily on the 2002 and 2009 Institute of Medicine (IOM) reports. Mr. Dorn refers readers to Table 3-3 in the 2009 IOM report America’s Uninsured Crisis: Consequences for Health and Health Care, which provides study counts, and to testimony from John Ayanian, a professor at Harvard Medical School. Professor Ayanian summarizes the 2009 report’s conclusions. Mr. Dorn’s work for the Urban Institute is also cited. It determined the number of deaths from lack of health insurance by accepting the IOM conclusions and extrapolating from them.

The problem with relying on the IOM reports is that they were not particularly scrupulous about determining whether mortality rates were caused by lack of health insurance or by behavioral differences for which being uninsured is a marker.

As previously reported on this blog, Appendix D of the 2002 Institute of Medicine cites only two studies on the topic of deaths from lack of health insurance, Franks et al. (1993) and Sorlie et al. (1994). It adopts the Franks estimate of 1.25 deaths among those without health insurance for every death among those with health insurance without explanation. The problem with this is that Franks’ sample assumed that baseline insurance status remained the same for 19 years, an unrealistic assumption, and it excluded everyone covered by government programs. The 95% confidence interval for the 1.25 hazard ratio was 1.00 to 1.55.

Wilper et al. (2009) would seem to support the IOM conclusions. The authors compared deaths through 2000 for the insured and uninsured based on their self-reported insurance status in NHANES III, a survey conducted between 1988 and 1994. The uninsured were 40 percent more likely to have died. The 95 percent Confidence Interval for the estimated hazard ratio ranged from (1.06 to 1.80).

Unfortunately, almost 30 percent of the Wilper sample was excluded due to missing data. Insurance status was self-reported, and the paper notes that 7 to 11 percent of the uninsured may be incorrectly classified. The study has no information about the duration of insurance coverage, it did not correct for income, and it excluded all people who had “public insurance,” including those on Medicaid, in the military, on Medicare, or in the VA system.

Kronick (2009) corrected for income and for other variables that are known to be correlated with mortality rates. He compared death rates as of 2002 for the insured and uninsured interviewed for the National Health Interview Survey between 1986 and 2000. About 20 percent of the sample reported not having insurance at baseline, and by almost every characteristic measured, they were in a higher health risk groups. Kronick found that “adjusted for demographic, health status, and health behavior characteristics, the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer-sponsored group insurance at base line.” He concluded that “the Institute of Medicine’s estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect.”

Several suggested articles shed little light because they look at the effect of disrupted health care on small samples of people who are sick and poor. The results from involuntarily cancelation for these people probably do not generalize to a larger, mostly healthy population in which many people choose to be uninsured. Studies from the 1980s by Lurie et al., “Termination from Medi-Cal — Does it Affect Health” (1984) and “Termination of Medi-Cal benefits. A follow-up study one year later” (1986) reportedly tracked 164 indigent adults who had been attending UCLA clinics and who had their care transferred from California Medicaid to county health facilities.

Fihn and Wicher (1988) compared 157 Seattle Veterans Administration Medical Center patients who had their outpatient care terminated due to budget cuts. The health of those who had their outpatient care involuntarily terminated deteriorated compared to 74 other people who were retained. The study concluded that “administrative criteria did not accurately identify medically stable patients,” that “federal health care programs are important to many indigent patients,” and that “withdrawing services may have deleterious consequences.”

Carlson et al. (2006) show that people who were dropped from Oregon Medicaid were less likely to have had a primary care visit and more likely to have unmet needs that those who were not dropped. The response rate to their random sample request was 34 percent.

Another group of references examines what happens to care when payments for care differ. Mr. Dorn’s article links to a seemingly random segment of the 2009 IOM report. Given that he discusses a study showing that the uninsured who are in severe auto accidents receive 20 percent less care than the insured, and die at rates that are 39 percent higher, let’s assume that he intended to refer the reader to Doyle’s (2005) empirical study of the effect of health insurance coverage on the amount of hospital care received following an automobile accident.

The study included 80 percent of all crash-related hospitalizations in Wisconsin from 1992 to 1997. Demographic differences were controlled for using the characteristics of the victim’s ZIP code of residence.

Professor Doyle found that the uninsured received fewer spinal fusions, skeletal traction, and operations on the brain, kidney, bladder, chest, large intestine, vessels and plastic surgery. They receive more sutures and more alcohol and drug rehabilitation and detoxification. The uninsured went to hospitals with fewer resources, and they had a mortality rate of 5.3 percent rather than the 3.8 percent enjoyed by the insured.

Based on the results, he concludes that a 10 percent increase in facility charges reduces mortality by 1.1 percent. This suggests that when higher payments for care result in more care, the extra care saves lives, at least for trauma patients. According to Doyle’s calculations, the estimated difference in the survival rates for the insured and uninsured translated into a 0.01 percent increase in the annual risk of death from an auto accident for the uninsured.

Card et al. (2009) measured how the health of seriously ill people, those for whom treatment could not be deferred and who were admitted through the emergency department, was affected by becoming eligible for Medicare at age 65. Their sample consists of a subset of all of the people aged 60 to 70 who were discharged from California hospitals from 1992 to 2002. As expected, these urgent admissions were unrelated to age, and predicted mortality rates rose smoothly with age.

Card et al. found “modest” increases in treatment intensity at age 65, on the order of 3 percent when measured by length of stay, list charges, and number of procedures. The data suggest that the increase in intensity is much larger for specific “procedure-intensive” diagnoses such as acute myocardial infarction, but the samples were too small to permit a definitive conclusion.

In accord with Doyle, the increase in treatment intensity observed by Card et al. seemed to produce a decrease in mortality for the seriously ill. As treatment intensity increased, the probability of death fell by 0.7 to 1.0 percent. Seven day death rates dropped from almost 5 percent just before age 65 to almost 4 percent just after age 65. Death rates a year after treatment dropped from roughly 23 percent to roughly 22 percent.

But nondeferrable admissions make up only 12 percent of the overall patient population. When Card et al. estimated the effect of turning age 65 on the entire set of discharged patients, they found that 28-day mortality fell by a small, and only marginally significant, 0.13 percent.

They conclude that the reduction in mortality that they observed was too large “to be driven solely by changes among the 8% of the patient population who move from no health insurance coverage to Medicare when they reach age 65.” They discuss several variables that may operate to reduce mortality, including the possibility that Medicare places fewer restrictions on care than private insurance or Medicaid “leading to more (and possibly higher-quality) services to patients over 65 than to patients under 65,” but conclude that the exact cause remains unclear.

Finally, they emphasize that their analysis “illustrates an important lesson for future research. Any plausible effect of insurance on health status in the general population will likely be small and easily confounded by selection effects in observational settings. Indeed, the only randomized health insurance experiment ever mounted found insignificant impacts of insurance on the health status of the overall population (Newhouse, 1993).”

Volpp et al. (2003) examined “The Effect of Cuts in Medicare Reimbursement on Hospital Mortality.” They found that when New Jersey reduced subsidies to hospitals that treated the uninsured, the hospitals performed fewer cardiac catheterizations and did less mechanical revascularization on uninsured patients admitted with heart attacks.

Meyers et al. (2006) surveyed 25 physicians working in Washington, D.C., who completed a survey on each of 409 patients seen in two one-half day sessions. They reported making changes in clinical management in response to insurance coverage with more changes made for the uninsured than for the privately insured.

Though papers by McWilliams and “colleagues” are mentioned but not specifically cited, likely candidates are McWilliams et al. (2009) “Medicare Spending for Previously Uninsured” and McWilliams et al.  (2007) “Health of Previously Uninsured After Acquiring Medicare Coverage.” The sample for the 2007 paper analyzed data from the Health and Retirement Study which enrolled people aged 51 to 61 in 1992. Subjects were questioned about self-reported health and health insurance status biannually through 2004. As 15.1 percent of the study sample died and 14.9 percent dropped out before 2004, results for this group were inferred. They did not control for demographic variables other than age.

Before age 65, summary health scores worsened at a greater rate for the uninsured than for the insured. After age 65, when the majority of both groups were covered by Medicare, health worsened for the previously insured while the health of the previously uninsured was relatively stable. Improvements were concentrated among those with cardiovascular disease or diabetes.

In “The Health Effects of Medicare for the Near-Elderly Uninsured,” Polsky et al. (2009) use data from the same Health and Retirement Study survey to estimate health state transitions in each two year period. In contrast to McWilliams, they find that gaining Medicare coverage had little effect on health. Their primary outcome measure is self-reported health status combined with mortality. Control variables include sex, age, education, ethnicity, race and census region. The change in health trajectory for the previously uninsured when they qualify for Medicare is small and “not statistically significant.” Specifically, for every 100 people in the previously uninsured group, by age 73 the effect of joining Medicare is that 0.6 fewer are in excellent or very good health when compared to the previously insured group, 0.3 more are in good health, 2.5 fewer are in fair or poor health, and 2.8 more are dead.

McWilliams et al. (2010) suggested that including deaths represented a potential source of bias “because previously uninsured adults were sicker than previously insured adults, and sicker adults were more likely to die.” By including deaths, Polsky et al. “implicitly assumed that the study design and statistical model were equally appropriate for both types of outcomes — health and mortality.”

Polsky et al. (2010) respond that death is “an important aspect of one’s health trajectory” and that their model allows hazard ratios to change as people spend more years on Medicaid. In an appendix to their 2009 article, they conclude that the problem is that the differences are driven by the fact that the previously uninsured who die after age 65 are more likely to be of excellent or very good health, and that health status comparisons are highly sensitive to accounting for the different character of deaths between the insured and the uninsured groups.

Professor Frakt’s references refer the reader to a final group of studies that are something of a hodge-podge. Most have little to do with health insurance or mortality. McGlynn et al. (2003) survey adults in cities and find that most people get half of recommended care. Decker and Remler (2004) compare the income gradient of self-reported health from surveys in Canada and the United States. They find that people below median income in the United States are 7.5 percent more likely to report being in poor or fair health than similar people in Canada.

Though they include two paragraphs that discuss the fact that the gradient grows, flattens and shrinks in other countries at the same ages during which the U.S.-Canadian gradient also grows, flattens and shrinks, they nevertheless conclude that universal health care reduces differences in health by income and that universal health care in the United States would reduce inequality “quite a bit.”

Finally, the RAND Health Insurance Experiment (HIE) is dragged in. It compared results for people with different kinds of health insurance, none of whom were uninsured. Professor Pollack directs readers to a 1983 abstract (Brook et al.) to support the claim that the RAND HIE predicted that low-income patients enrolled in a high deductible health plan would have a 38 percent higher mortality rate than those enrolled in a free plan due to differences in hypertension. However, the abstract merely says that diastolic blood pressure was 3mm Hg lower for those with free care.

In the definitive book on the RAND experiment by Joseph P. Newhouse and the Insurance Experimental Group, Free For All?, the effect of the lower blood pressure is said to reduce predicted mortality rates by about 10 percent (p. 339). Furthermore, Newhouse et al. concluded that “virtually all of the improvement in blood pressure control brought about by free care occurred as a result of better identification of hypertensives…Control, once the person was diagnosed, was not measurably affected by cost sharing.”(p. 352). The RAND HIE researchers concluded that for most of the American population “free medical care in an ‘unmanaged’ fee-for-service system is not worth its costs. The burden on the poor and on persons (particularly the poor) with chronic conditions is a separate issue and should be dealt with as such.” (p. 357)

Comments (30)

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  1. Kyle says:

    Very thorough — it belongs in a scholarly literature critique. +1 Dr. Gorman. It’s nice to see people actually paying attention to the quality of research instead of throwing out citations.

  2. Jordan says:

    For shame, Frakt. For shame.

  3. Gary Fradin says:

    I think we’re learning that public health investments – clean air, water, transportation etc – have bigger population health benefits than does investment in medical care and technology. Richmond & Fein made that argument in The Health Care Mess, 2005 (page 92 ‘a growing professional consensus held that the various health gains [since WWII] were largely the consequence of progress in applying our knowledge of health promotion and disease prevention rather than improved clinical care’)

    In other words, longevity is largely a function of non-medical factors. I worry that our huge medical care expenditures reduce our ability to invest in the things that actually lead to longer lives.

    Nonetheless, people do get sick, and when they do, timely medical care can help. The IOM identified lack of medical insurance as a reason that some people get too little care, too late in the disease cycle.

    I certainly don’t know the right approach to providing ‘appropriate’ insurance and medical care. And – quite depressingly – neither, it appears, does anyone else.

    But I suppose it’s at least useful to agree on the facts first and let them become the basis of policy recommendations.

  4. Patel says:

    Once again, the emphasis is too much on insurance, but not on health. There are better ways to promote health than having to rely on insurance to make that happen.

  5. Desai says:

    I don’t think it is lack of health insurance that is killing people, I think it is the unhealthy life styles most of us are living today. And lets be real, trying to lead a healthy life style in a contemporary urban setting is just hard!

  6. Huda says:

    I am sure Austin Frakt will have something to say about this!

  7. Kumar says:

    The mess with health care is the lack of access to affordable care, insurance isn’t the only solution. The real problem is the the lack of free market competition in health care, we are supply locked by the hospital oligarchies.

  8. Hassan says:

    We should just do away with health insurance and try to go by a market place where the consumer directly interacts with the buyer!

  9. Buster says:

    Being uninsured doesn’t kill people any more than having Medicaid or private coverage. Moreover, having private coverage doesn’t save people from death any more than Medicaid or private coverage. What saves them is medical care, which interacts with their natural stock of health of health status. Over the long run, mortality is 100 percent. Mortality can often be slowed through healthy behaviors or health-seeking behavior. It’s not the type of health coverage that matters, it’s the type of behavior.

  10. Ki Ki says:

    Are we talking about insurance again!? Why? I thought Obama Care took care of this?

  11. Gabriel Odom says:

    The data says that not having insurance is correlated with higher mortality. The data does NOT say that not having insurance CAUSES higher mortality.

    Not having insurance can be caused by a variety of factors:
    Being poor. Lower incomes are often correlated with higher mortality. Additionally, we can easily argue that lower income causes higher mortality.
    Being irresponsible. Most responsible people either are healthy enough to know that they don’t need health insurance, or they know that they need the insurance. Either way, it’s often irresponsible people who do not go through the effort to get insurance. As a reinforcing effect, these same people often make poor lifestyle choices (smoking , eating unhealthily, remaining sedentary, reckless behavior, etc.) that increase their chances of harm or injury.

  12. H. James Prince says:

    +1 Buster and Gabriel

  13. Greg Scandlen says:

    Excellent work, Linda. Let me add a very short piece I did for NCPA eleven years ago – Looking at health status in five different countries shows the people who are poor and poorly educated have worse health regardless of the presence of insurance coverage. This is so basic that any “study” that fails to control for income and education should be instantly discredited. Austin Frakt should know this.

  14. Ken says:

    Thanks, Linda for this excellent review of the literature.

  15. Tiger says:

    I’d rather be insured than uninsured.

  16. Al says:

    From what I have seen on his blog Austin Frankt loves to quote himself and is blind to alternative ideas that disagree with what he believes was written with his golden pen. Don’t post if you disagree and be prepared for deletion. Opinion and insults on that blog seem to travel in only one direction.

    I guess that is the answer to Austin Frankt’s dilemma “It seems like TIE doesn’t count” ” It seems like we’re stuck at the kids’ table.” (2/21/13)

    Great post Linda.

  17. James says:

    OK, so I guess the overall conclusion is that having health insurance doesn’t matter in terms of outcomes. So, what’s the point of being insured?? How many of the insured on this post would be willing to cancel their insurance policies??

  18. Al Baun says:

    I think Dr. Goodman is trying to dig himself out from his last article. The hole is getting deeper.

    This article, as did the last one, supports the ‘Oregon report’s’ implication that Medicaid, and the preventative services afforded to low income individuals by it, has little affect on general health or mortality rates of those tested. In addition, it draws the conclusion that low income people have little interest in preventative care or healthy lifestyles. One might draw the conclusion that Dr. Goodman favors elimination of Medicaid and preventative services in general.

    Thankfully, Dr. Goodman is not in a position to implement those tenuous ideas. If he had looked into the Kaiser Prenatal Care Studies, infant mortality in its self would have accounted for his mysterious 45,000 premature deaths.

    As far as the efficacy of preventative care in general, if the Doctor chooses to ignore countless studies and common sense practices of catching maladies before they become big problems, I can see why he spends his time writing instead of healing. Insurance companies even know the value of preventative care.

    Thank goodness for Obamacare and availability of preventive services to everyone … whether they use it or not.

  19. John Goodman says:

    @ Al Baum

    I am on record — many times in many different places — as an advocate of a universal, refundable tax credit for health insurance and health savings accounts.

    I am also on record for allowing anyone to buy into Medicaid — adding cash to their tax credit to do so — and allowing anyone who is on Medicaid to add cash to their expected Medicaid benefit and buy into private coverage instead.

  20. Ralph Weber @ MediBid says:

    It has been my consistent experience that if you place people into 2 distinct groups; Those who have health insurance, and those who don’t. For the most part, people in the first group tend to be largely more responsible people who take care of themselves better. I don’t think that just “having” health insurance does a damned thing.

  21. Al says:

    @James: “How many of the insured on this post would be willing to cancel their insurance policies??”

    James, I find the major point of being insured is to protect my assets. If I were building one (an asset) and health insurance stopped me from doing so I would get rid of health insurance.

  22. Linda Gorman says:

    I think that it is important to keep in mind that these results are for the US system, in which (until recently) people have routinely had unusually extensive access to sophisticated medical care whether or not they can pay. They also can access a wide range of basic services with low or no income.

    They obviously would not apply in a world in which trauma centers and EDs check the ability to pay at the door and refuse to treat those without adequate financial resources.

    Why have health insurance? It protects one’s assets in the event of an unusually expensive health crisis. And those who pay for their care get better care, as one would expect.

  23. Wanda J. Jones says:

    Linda and John and Colleagues:

    This is a very important point. It, like many others you have published touch on the persistence of urban myths. As we will probably be in the miasma of health policy arguments for decades, it seems obvious to me that you all need to produce a compendium of such myths and their refutations suitable for use by committee staffers to lay a rational foundation for their laws and regs. I suggest using a format that maximizes understanding–with a graphical display of the topic and its consequences on the left, to be read by the right brain, and text on the right to be read by the left brain. Think 15 seconds per topic.

    THis blog is a keeper. Good work, Linda.

    Wanda J. Jones, MPH
    New Century Healthcare Institute

  24. mark fahey says:

    A few years ago the Institute on Medicine said that the health care system kills over 100,000 people per year by mistakes, negligence, or iatrogenic injury/infection.

    So if you have health insurance you get more care than if you’re uninsured. seems like the odds are better to be uninsured and stay away from the health care system if being uninsured only kills 45,000. Which way does the IOM want it. I think both of these claims like many by the IOM are equally suspicious and extrapolated from dubious data.

  25. Erik says:

    As a cancer survivor I can tell you I would not be here today without insurance. My cancer was found during my annual check-up.

    Let’s face it, we all believe what we want to believe.

  26. John Fembup says:

    “My cancer was found during my annual check-up.”

    Your insurance agent must be better at check-ups than mine.

  27. suzy says:

    Health insurance is killing me. The pills are right there. Insurance cancelled my surgery that was scheduled a week ago. My leg is going numb, dying every day. I want to die I can’t take the torture.There is no one to call, just insurance admnistrators that get rewarded for refusing care. Those overdoses are not accidents.

  28. John Fembup says:

    “There is no one to call, just insurance admnistrators”

    I would advise calling your doctor. Soon.