The deadly cost of being uninsured

On average, Americans spend more than twice as much on health care costs per person each year than do people in 34 other countries, according to the Organization for Economic Cooperation and Development. That’s $8,233 spent on health care costs per individual in the United States, versus $3,268 elsewhere.

The U.S. nonetheless remains the only wealthy country that fails to provide universal health insurance. And only in the U.S. is there a serious debate about the value of insurance coverage for protecting health. 

Eight million Americans nationwide have signed up for insurance on the exchanges through the Affordable Care Act (ACA). Millions more not entitled to subsidies have enrolled directly with insurance companies, and several million Americans have gained coverage through Medicaid in Democratic-led states.

A Gallup poll out this week shows an additional 12 million Americans are newly insured in 2014 — and yet 48 million are still not covered. The extended sign-up period for the ACA expired this week in some states, including California, and some of these uninsured will face tax penalties for not enrolling. 

But 24 Republican-led states also declined federally financed Medicaid expansion for their low-income, uninsured residents in 2014. ACA critics have renewed their argument that Medicaid coverage actually “harms the poor.”

An enormous body of research shows this is false. In fact, this growth in coverage from the ACA is likely to have a dramatic effect on the health of the previously uninsured.

For more than 40 years, studies have documented that continuously or intermittently uninsured adults have fewer doctor visits and receive less preventive care, such as blood pressure screening, Pap tests, cholesterol testing or influenza vaccinations. 

A recent study of preventable leg amputations describes an uninsured 53-year-old woman with undiagnosed diabetes who was regularly drinking six-packs of ginger ale and other sweetened beverages. She reported that she “felt like a junkie looking for something to quench [her] thirst.” She went into a diabetic coma and wound up hospitalized. Her infected toes required an amputation.  

Prevention of this outcome could have been achieved through regular checkups and diabetes medications. But what if doctors’ visits, tests and drugs are unaffordable? Similarly, screening colonoscopies to detect colon cancer and mammograms for breast cancer cost hundreds of dollars and are often unavailable or require years on a waiting list at public hospitals or clinics.

It is not surprising, then, that the uninsured are diagnosed at more advanced stages of cancer, especially for cancers that are detectable by screening. The uninsured have much higher rates of undiagnosed high blood pressure and high cholesterol, are at higher risk for more severe strokes and have poorer control of diabetes.

After the age of 50, major declines in general health and physical functioning for the uninsured as compared with the continuously insured become most significant, as that is when health complications become more common. After the age of 65, when they finally become eligible for Medicare, the uninsured then have disproportionally greater gains in health.

Because seriously ill patients cannot be turned away from the emergency room, many uninsured get hospitalized, but have consistently poorer outcomes. For instance, one study of unconscious patients hospitalized after severe motor vehicle crashes found that the uninsured received less care and had a 40 percent higher mortality rate than insured patients. That higher rate exists even after controlling for type of vehicle, injury, auto insurance, income, neighborhood and hospital characteristics.

The uninsured not only suffer from health declines — they also die earlier.

Studies following older middle-aged (ages 51–64) adults into old age demonstrated that individuals who were uninsured died at younger ages when compared with those of the same age and original health status who were privately insured. 

The one-third greater mortality of older adults who lacked health insurance was roughly equivalent to the risk of smoking. The lack of health insurance in older middle age could rank as the third leading cause of death, behind heart disease and cancer.

A 2009 study based on a representative sample of the U.S. population and adjusted for detailed health information estimated that between 35,000 and 45,000 Americans ages 18–64 die annually due to lack of health insurance.

It is difficult to detect the health effects of being uninsured, because at any point most of the uninsured are healthy. When major health declines or illnesses do occur, previously uninsured individuals then qualify for disability and Medicaid. 

Being uninsured is often a temporary condition, with individuals cycling in and out of employment-based insurance as they change or lose jobs. And the uninsured do receive health care at public hospitals, clinics and hospital emergency rooms. It has thus remained difficult to demonstrate convincingly that providing health insurance to the uninsured will have a major effect.

One widely publicized study published in The New England Journal of Medicine in 2013 attempted to do just that: It analyzed the health and financial effects of expanding Medicaid for the uninsured in Oregon. The study was based on the state’s decision to conduct a lottery to fill 10,000 additional Medicaid slots for low-income, uninsured residents.

Researchers were able to compare health and financial outcomes of Medicaid lottery winners to lottery losers over the next two years. Individuals who won the lottery had a greater chance of having a physician visit, getting blood cholesterol or blood sugar tests, and receiving a diagnosis of diabetes and thus obtaining diabetes medications. 

Although blood pressure, cholesterol and diabetes control were not significantly different, there was a 30 percent reduction in symptoms of depression among insurance lottery winners. Significantly more of these lottery winners reported that their health was the same as or better than the previous year. Lottery winners had a 25 percent lower rate of unpaid medical bills sent to collection agencies, and catastrophic medical expenditures were reduced by more than 80 percent, compared with lottery losers.

Critics of the study pointed to the lack of short-term clinical differences between winners and losers and dismissed lottery winners’ gains in self-reported quality of life as mere perceptions.

However, a longer-term, earlier study, also published in NEJM, compared states providing expanded Medicaid coverage to low-income, childless adults between 1997 and 2007 with neighboring states that did not expand Medicaid. 

The study found that states that expanded Medicaid decreased lack of insurance by 15 percent. And these expansion states had a 6 percent decline in deaths of adults ages 20–64 in the five years after Medicaid expansion. The study concluded that only 176 additional adults would have to be covered by Medicaid to prevent one death per year. 

The political debate over the Affordable Care Act has reached ludicrous proportions, as Republican politicians attempt to block national surveys that collect data about insurance coverage rates, presumably to prevent President Barack Obama’s administration from taking credit for what will be major declines in lack of insurance.

But whether to provide coverage for the low-income uninsured is not simply a matter of politics — it is about saving lives and needless suffering.