Does Lack of Insurance Cause Premature Death? Probably Not.

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

“An estimated 17,000 children in the United States might have died unnecessarily over nearly two decades because they didn’t have health insurance,” said U.S. News and World Report. “The authors estimated that at least 1,000 hospitalized children died each year simply because they lacked insurance,” said The New York Times.

They’re talking about a Johns Hopkins Children’s Center study [gated, but with abstract]. But between the media hype and the actual study is an enormous chasm that separates fact from fiction. In truth, the authors of the study did not establish that anybody, anywhere, died of any cause whatsoever because of a lack of health insurance.

This is only the latest in a series of ridiculous claims that have been injected into the health insurance debate. What follows is a brief review, some of which has appeared earlier at the Health Affairs blog.

It’s life’s illusions I recall

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 one of us previously explained, 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 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 Frank’s 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 that report.

Not to be outdone, the Physicians for a National Health Program (PNHP) 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 is 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 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. People are receiving appropriate care a little better than half the time when they see doctors. According to RAND, the care patients receive is not affected by whether they are insured or uninsured 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!

The Johns Hopkins study at least has one advantage over all the other studies: The authors knew the insurance status of the children at the time they died. After combing hospital records over a 20-year period, they determined that although children admitted to hospitals rarely die, those who did were 60% more likely to have been uninsured. But does that mean that uninsurance is the reason? The authors offer no theory connecting uninsurance with health and no specific theory is tested.

Of children admitted to hospitals who did not die, the average length of stay (two days) is the same for the insured and the uninsured. The cost of care is about 90% the same. This is consistent with the RAND results. However, among children who died, the length of stay for insured children is longer and more varied, and the cost of care is 2½ times higher than for the uninsured. In fact, more than half of the uninsured children who died did not remain in the hospital for even a single day — which suggests that many died in the emergency room or were DOA. It seems likely, therefore, that among those who died, the insured and uninsured were very dissimilar.

The most common reasons for children being hospitalized were complications from birth, pneumonia, and asthma. The study found that the reasons did not differ by insurance status.

What did differ was the fraction of deaths in the older uninsured population, particularly those aged 11-18. This matters because there is an extensive literature chronicling the fact that child accident and homicide rates, which have the largest effects on teenagers, are inversely related to parental characteristics like income, and educational attainment, directly related to parental levels of substance abuse, and a function of marital status and living arrangements.

In the early 2000s, motor vehicle accidents, drowning, burns, and poisoning, cause more than a third of all deaths among children aged 1-19. Homicide was the 4th leading cause of death in 1-4 year olds, 5-9 year olds, and 10-14 year olds. It was the 2nd leading cause of death in 15-19 year olds. [link, link] Lack of insurance is unlikely to contribute to deaths by homicide, motor vehicle crash, drowning, burns, or poisoning.

Remarkably, this paper is silent on whether people living in conditions that make their children more prone to accidental death or homicide are also less likely to have health insurance.

Richard Kronick has a review of the literature on what we know about those who lack health insurance in the August issue of Health Services Research. He writes:

There would not be much change in the number of deaths in the United States as a result of universal coverage, although the difficulties in inferring causality from observational analyses temper the strength of this conclusion.

As for the public policy implications of all this, 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 find that:

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

Comments (36)

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  1. Larry C. says:

    Great post. Thanks so much for clearing all this up.

  2. Ken says:

    Agree with Larry. This is really great stuff.

  3. Devon Herrick says:

    Whether or not a family has health coverage is probably related to a combination of risk aversion and income. If income is low and risk aversion is low, families would have a much higher likelihood of being uninsured. I would imagine their children would also have a higher likelihood of dying while engaged in a risky behavior. Examples of this could include: drowning while unsupervised, dying in a car crash while not wearing a seatbelt, getting hit by a car while jaywalking or playing too near the street, etc. Thus it is easy to see how lack of health coverage could be correlated with premature death but not a cause of it.

  4. Joe S. says:

    Great peice.

  5. Larry C. says:

    This is really good. Congratulations to Linda and John. This piece explains away a lot of nonsense that we see so often in the news media.

  6. Martin Brooks says:

    So, if there is no difference in outcomes between the insured and uninsured why would anyone waste money on insurance?

  7. George says:

    Good question, Martin, and the best answer is probably that one should not spend money on insurance, rather on medical services that are relevant to their health status and need.

  8. R Allan Jensen says:

    Martin, George::

    Good question. The answer is that insurance is a mechanism to “finance” one’s health care costs, within the parameters of the contract one has with the insurance company. To the extent that a person needs an insurance policy to finance the costs that they themselves cannot, at any particular point in their lives, they should consider an insurance plan.

  9. Marti Settle says:

    Health Care can be a danger to your children too:

    My first born child, a daughter, received her second DPT shot in August 1967 at the age of 5 1/2 months. Within 10 days she was having seizures and nystagmis. Within days she was completly brain damaged and died 20 months later. Thanks to good, conscience health care rendered in a timely manner as proposed by the AMA and the pediatricians. This “panic legislation” will kill more people than it saves. Trust me. Sometimes people are better off roughing it at home with chicken soup.

  10. Ralph W. says:

    Most doctors will hesitate to check the box on the death certificate that says: “Cause of death, no health insurance”, because it would imply that they broke the Hippocratic oath by withholding life saving medical care.

  11. Martin Brooks says:

    R Allan Jensen:

    ‘To the extent that a person needs an insurance policy to finance the costs that they themselves cannot, at any particular point in their lives, they should consider an insurance plan.’

    Sorry, but why? If I get cancer and I’m uninsured, Goodman and co say there’s no evidence I will be disadvantaged in mortality, presumably because I’ll get the same care some way (what ways…)

  12. Jerry K. says:

    It is preposterous to think people die becasue they don’t have health insurance. It is not however preposterous to deduce that people die becasue they do have health insurance. Using the widley used IOM report that estimated the number of deaths by error in the nations hospitals each year at 90,000 times twenty years would be 1.8 million deaths — by error. I wonder if some of these were from surgeries and procedures that were not necessary but perfomred since the patient had insurance – nah wouldn’t happen !

  13. Jennie Fiedler says:

    There is disinformation on both sides of this debate. Death due to lack of insurance, and on the other side “death panels” and “rationing”. I am insured, and I can tell you, your healthcare is still “rationed”, depending on whether or not your insurance company has found a way to deny your benefits. It’s a debacle to be sure, and personally I think its reasonable to want to pay for health coverage, and not private jets, bloated salaries, boondoggles, bonus incentives for above-mentioned denials of benefits, and big, fat investor profits. In fact, it’s becoming clear to me that if not for those very things, we probably wouldn’t be in this raging debate or the national crisis that sparked it.

  14. Linda Gorman says:

    If one is buying real health insurance, one does it to protect assets and to not be dependent on charity care if one becomes really, really sick.

    If one is buying a health plan sponsored by an employer or government, one buys in hopes that someone else will pay one’s health care bills.

    The claim that the public sector rations in the same manner as private insurance companies is not supported by the evidence. All you have to do to see that is to take a look at who has to wait in government controlled systems and who has to wait in the US private system.

    Or take a look at the NCPA Brief Analysis on how the Oregon Health Plan’s politically rationed priorities compare to those of private medicine and insurance companies. http://www.ncpa.org/pub/ba645/

  15. Linda Gorman says:

    The IOM report on error has been deconstructed and found wanting. One of the authors who did the analysis of medical error that they based the report on stated, in a professional journal, that they misused his estimates.

  16. Don Levit says:

    Linda:
    If one is buying real health insurance to protect assets, then shouldn’t the maximum benefit correspond to one’s net worth?
    Don Levit

  17. Linda Gorman says:

    Don, your right.

    Everyone knows that there are horrible diseases out there that could easily cost more than one’s net worth to treat. So another reason for buying health insurance is to have the money to pay for treatment without having to depend on the tender mercies of government or charitable organizations.

    Otherwise, why would the British or Canadians buy private health insurance? Which they do.

  18. Don Levit says:

    Linda:
    When a person buys insurance exceeding his net worth, in order to not depend on government or charity,he should get a deduction for the excess.
    Aside from that, though, if one buys insurance in order to attempt to pay the entire inflated bill, isn’t he being an “enabler” – enabling medical expenses to continue to outpace inflation and wages?
    In that case, isn’t insurance actually hazardous to one’s health?
    Don Levit

  19. Lauri Sliney says:

    We need to get away from health insurance in this country. It’s what is driving up costs of medical care. Personally, if I were allowed to do so, I would forego the standard health insurance that is costing me nearly $600 a month and buy a catastrophic/major medical policy that, when they were readily available back in my parents’ day, cost pennies per month. I would then take my savings and put in a health savings account, but only if HSA’s were allowed to roll-over from one year to the next (currently they are not). My family is generally healthy, so we use very little of our insurance. We could easily pay for our occasional trips to the doctor while remaining insured against overwhelming major medical expenses. If everyone had such an option, we’d all force our doctors to compete for our dollar, which would drive down the cost and improve the quality (competition always does that).

    Linda, correction — the British can buy private health insurance and do, but the Canadians face legal penalties for doing so, which is why they come here and pay medical expenses out of pocket.

  20. Linda Gorman says:

    Lauri,

    HSAs do roll over from one year to the next. Are you perhaps thinking of flexible spending accounts? And policies with large deductibles ($5,000 to $10,000) are available in a lot of states.

    Canadians can buy health insurance to cover things not covered by provincial Medicare plans. They can also purchase critical illness insurance which gives a lump of cash if one is diagnosed with any of a number of conditions. A typical website is at http://www.coverme.com/help-me-choose/critical-illness.jsp?MKT=W9G. Note that it points out that “you may even have to travel to get the medical attention you need.”

    Other supplemental policies, including Rx, dental, emergency transport, and “extra” hospital costs are described at http://www.kanetix.ca/health-insurance.

  21. Patrick Skinner says:

    John, we enjoy and appreciate your comments on our healthcare system.

  22. Jason says:

    Great article. Very insightful.

  23. DavidC says:

    Let me try to argue (facetiously) that contrary to the belief that lack of health insurance increases your chance of death, it is health care itself that increases your chance of death. After all, some 77% of all deaths occur at a healthcare facility. That’s a mighty high correlation between health care and death. Maybe if I didn’t have access to health care, my chances of survival would increase! Needless to say such an argument is just as specious as the ones Linda and John debunk.

  24. [...] canard that there are 45,000 people (just like John!) who die every year from lack of insurance, Linda Gorman and I have dealt with that ridiculous claim [...]

  25. [...] John Goodman at NCPA has a thorough analysis of the literature. Here’s an excerpt, but be sure to read the whole thing: 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. [...]

  26. [...] it refers to one study’s estimate of that number. Other studies, cited by Michael Cannon and John Goodman among others, suggest that the number is considerably closer to zero — or else that the link [...]

  27. mulp says:

    So, the argument is that if you become poor because of a health condition and thus become uninsured, your death while uninsured is a consequence of being poor from going bankrupt, not from lack of adequate health insurance?

    If it weren’t for Medicare, I’d guess 90% of all deaths in the US would be caused by poverty, not lack of insurance. I base this on a $5000 deductible individual policy costing $9400 a year at age 62 – what would a policy cost at age 65, 70, 75? How many in the US could afford health insurance at those rates?

    And the evidence for conservatives being more willing to accept responsibility and save for the future if only government didn’t steal their money is clearly lacking. As taxes have been cut and the claims of Americans becoming more conservative been stronger, the savings rates and assets as old age approaches suggest that conservatives will die poor.

  28. Damany I. says:

    this is absolute nonsense.

    Harvard study says different.
    http://www.harvardscience.harvard.edu/medicine-health/articles/new-study-finds-45000-deaths-annually-linked-lack-health-coverage

    Are you going to believe this guy’s blog or trust the Harvard study?

  29. Damany I. says:

    Mulp, When you lose your job you lose your insurance right? So if we had a mechanism in place that doesn’t allow you to lose your healthcare, the number of deaths due to lack of care would be zero. For countries with a single payer system, that number is ZERO.

  30. [...] R&D through the NIH, and some targeted public health expenditures.” The first supposition is without any scholarly basis and the second is far from [...]

  31. Vanessa says:

    “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”

    Regarding the quote above:

    So we shouldn’t mourn over the 3% of the estimated 46 million uninsured who are more likely to die!?! That 137,100 people!! We shouldn’t mourn over the loss of more than a hundred thousand people? Call me a bleeding heart, but I think that’s tragic.

  32. JMZ says:

    At most, this article disputes some of the methodology of the studies – so maybe 25,000 people are dying every year from lack of insurance, instead of 45,000. What a great point.

    If there were any justice in this world, the person who wrote this article would lose their job, come down with lupus, and then end up in the emergency room after avoiding a doctor to avoid bankruptcy. Of course, I would never wish that on anybody. But the head-up-my-ass heartlessness of some people in this country truly astounds me.

    And then other people have the gall to respond with “great piece.” Have fun sleeping at night while your next-door-neighbor’s wife is dying of treatable breast cancer, folks.

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