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Mortality risk likely to be higher among uninsured patients

With the Congressional Budget Office report indicating that 22 million Americans will lose insurance coverage by 2026 under the Senate’s proposed Better Care Reconciliation Act, a recent study published in Annals of Internal Medicine shows that a lack of insurance is associated with increased mortality.

In this study, Steffie Woolhandler, MD, MPH, and David U. Himmelstein, MD, from City University of New York School of Urban Public Health at Hunter College and Harvard Medical School, summarized the current evidence relating to the connection between insurance and mortality. Currently, approximately 28 million people in the United States are uninsured, and the repeal of the Affordable Care Act (ACA) will cause millions more to loss coverage. In the face of these legislative changes, some policy leaders are advocating for a single-payer national health insurance system that would provide every American with insurance coverage.

In 2002, an Institute of Medicine concluded in a review that mortality increases among people without health insurance. A growing body of evidence collected since that report confirmed previous findings that health insurance saves lives, and revealed that the odds of dying among the insured compared to the uninsured is 0.71 to 0.97. That report concluded that “the uninsured have poorer health and shortened lives.”

Although these findings strengthen the evidence that health insurance reduces mortality, the authors acknowledge that several factors complicate these results, including that most evidence comes from observational and quasi-experimental analyses. However, the authors also noted that a definitive, randomized control trial may not be possible, therefore decisions have to be based on the best preponderance of evidence.

Researchers focused on analyses published subsequent to the IOM report, controlling as much as possible for the fact that publicly insured individuals have, on average, worse baseline health, by excluding most observational studies comparing the uninsured with those insured by Medicaid, Medicare or the Department of Veterans Affairs. Children were excluded because of the rarity of deaths following the neonatal period and the elderly because the majority are covered by Medicare.

The Oregon Health Insurance Experiment studied the effects of a 2008 lottery in Oregon that opened a limited number of Medicaid slots to poor, able-bodied uninsured adults. After 1 year of follow-up, the death rate among those not selected in the lottery was 0.8%, 0.032% higher than those selected, a “dose-adjusted” difference of 0.13 percentage points annually. This was not statistically significant, which was not surprising given the low power of the study, low mortality rate and short follow-up, the authors reported. However, those were selected had better self-rated health, were more likely to have diabetes diagnosed and treated and were less likely to be diagnosed with depression.

An analysis of the 1971-1975 National Health and Nutrition Examination Survey (NHANES) found that by 1987, the mortality rate for insured patients was 9.6% compared to 18.4% among the uninsured; adjusting for baseline characteristics and health status, the hazard ratio for uninsurance was 1.25 (95% CI, 1.00 to 1.55). A subsequent review of data from the 1988-1994 NHANES, with follow-up through 2000, found uninsurance to have a mortality hazard ratio of 1.40 (95% CI, 1.06 to 1.84).

“Overall, the case for coverage is strong. Even skeptics who suggest that insurance doesn't improve outcomes seem to vote differently with their feet,” Woolhandler and Himmelstein wrote. “The evidence accumulated since the publication of the IOM's report in 2002 supports and strengthens its conclusion that health insurance reduces mortality.”

“Finally, our focus on mortality should not obscure other well-established benefits of health insurance: improved self-rated health, financial protection, and reduced likelihood of depression,” they wrote. “Insurance is the gateway to medical care, whose aim is not just saving lives but also relieving human suffering.”

The ACP, AAFP and other health care organizations have openly opposed and criticized the repeal and replacement of the ACA. The proposed Senate Better Care Reconciliation Act (BRCA) of 2017 will slowly phase out of Medicaid expansion and funding cost-sharing exchange plans for 2 years. The CBO report further confirms that the provisions in the BCRA and the American Health Care Act will fail to protect Americans and will make insurance harder to afford.

“The U.S. Senate must act, at minimum, to preserve the coverage gains achieved under current law and not take regressive actions that will harm millions of Americans,” John Meigs, Jr., MD, AAFP president, said in a statement. “We call on the U.S. Senate to do the right thing for patients by working to achieve real bipartisan solutions to further expand coverage and ensure that coverage remains affordable; that the individual market is stabilized; that long-term, adequate funding for the Medicaid program continues; that primary, preventive, and mental health and substance use services are more readily available to all Americans; and that the cost of pharmaceutical treatments is reduced.” – by Savannah Demko

Disclosures: Woolhandler and Himmelstein report serving as unpaid advisors to Bernie Sanders' presidential campaign and were founders of and remain active in Physicians for a National Health Program. Meigs is president of the AAFP.