T h e a b s e n c e o f h e a l t h i n s u r a n c e c r e a t e s a r a n g e o f c o n s e q u e n c e s , i n c l u d i n g l o w e r q u a l i t y o f l i f e , i n c r e a s e d m o r b i d i t y a n d m o r t a l i t , a n d h i g h e r fi n a n c i a l b u r d e n s . T h i s p a p e r f o c u s e s o n j u s t o n e a s p e c t o f t h i s h a r m — n a m e l , g r e a t e r r i s k o f d e a t h — a n d s e e k s t o i l l u s t r a t e i t s g e n e r a l o r d e r o f m a g n i t u d e .
In 2002, the Institute of Medicine (IOM) estimated that 18,000 Americans died in 2000 because they were uninsured. Since then, the number of uninsured has grown. Based on the IOM s methodology and subsequent Census Bureau estimates of insurance coverage, 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006.
Much subsequent research has continued to confirm the link between insurance and mortality risk described by IOM. In fact, subsequent studies and analysis suggest that, if anything, the IOM methodology may underestimate the number of deaths that
result from a lack of insurance coverage.
More broadl , these estimates should be viewed as reasonable indicators of the general magnitude of excess mortality that results from lack of insurance, not as precise “body counts.” The true number of deaths resulting from uninsurance may be somewhat higher or lower than the estimates in this pape , but that number is surely significant.
The IOM methodology
T he IOM’s 2002 report, Care Without Coverage: oo Little, oo L a t e , d e s c r i b e d t h e c o n s i d e r - able research showing that the absence of health coverage impedes access to care, which ultimately increases the risk of illness and death. Uninsured women with breast cancer, for example, have their disease diagnosed later during its development, when treatment is less effective (Ayanian et al. 1993; Roetzheim et al. 1999, 2000; Lee-Feldstein et al. 2000; cited in IOM 2002). Uninsured men with hypertension are more likely to go without screenings and prescribed medication and to skip recommended doctor visits, increasing the likelihood of serious harm (Ayanian et al. 2000; Keeler et al. 1985; Huttin, Moeller, and Stafford 2000; Fish-Parcham 2001; cited in IOM 2002).
As part of the IOM report, the authors sought to estimate the total number of deaths resulting from uninsurance. They began developing this estimate with two long-term, longitudinal studies observing the relationship between insurance status and death rates. One used 1971–87 data on 25- to 74-year- olds from the National Health and Nutrition Examination Survey (Franks, Clancy, and Gold 1993). The other used Current Population Survey (CPS) data on 25- to 64-year-olds from 1982 to 1986 (Sorlie et al.1994). Although the two
study populations differed, as did the potentially confounding characteristics for which the researchers controlled, both studies yielded estimates attributing to uninsurance an overall increase of 25 percent in mortality risk for working-age adults.
The IOM study combined this research result with information on the num- bers of deaths and the percentages of people who are insured by 10-year age intervals. IOM researchers developed the following formula, which starts with the straightforward proposition that the number of total deaths in an age group is the sum of (a) deaths among insured members of that age group and (b) deaths among uninsured members of that age group.
DT = DI + DU = (PI*X) + (PU*X*1.25), where
DT = total deaths in a particular age cohort
DI = deaths among the insured in the age cohort
DU = deaths among the uninsured in the age cohort
PI = percentage insured in the age cohort
PU = percentage uninsured in the age cohort
X = the number of deaths that would occur if everyone in the age cohort had insurance.
Note that DU, or the number of deaths among the uninsured, is calculated through two steps. First, the IOM methodology ascertains the number of deaths among the uninsured as if every- one in the age cohort had insurance. That number is X (or the total number of deaths if everyone in the age cohort had insurance) times PU (or the proportion of people in the age cohort who lack insur- ance). Second, the number of deaths as if the uninsured had insurance is mul- tiplied by 1.25. This yields an estimate of the actual number of deaths among the uninsured, reflecting the 25 percent higher mortality rate among the unin- sured found by the above-described research.
Using the IOM’s analysis of 25- to 34-year-olds to illustrate this calculation, mortality estimates from the National Center for Health Statistics (NCHS) showed that 40,548 adults age 25–34 died in 2000. Accordingly, for this age group, DT = 40,548.
At the time of the IOM report, data from the CPS reported that 79 per- cent of adults age 25–34 were insured and 21 percent were uninsured in 2000, providing the values for PI and PU, respectively. Using these figures in the above formula produces the equation:
40,548 = (.79*X) + (.21*1.25*X) = (.79*X)
(.26*X) = (.79+.26)*X = 1.05*X
Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality