Health Insurance Coverage and Mortality Revisited

Department of Family and Preventive Medicine, Division of Heath Care Sciences, UCSD School of Medicine, La Jolla, CA 92093-0622, USA.
Health Services Research (Impact Factor: 2.78). 05/2009; 44(4):1211-31. DOI: 10.1111/j.1475-6773.2009.00973.x
Source: PubMed

ABSTRACT To improve understanding of the relationship between lack of insurance and risk of subsequent mortality.
Adults who reported being uninsured or privately insured in the National Health Interview Survey from 1986 to 2000 were followed prospectively for mortality from initial interview through 2002. Baseline information was obtained on 672,526 respondents, age 18-64 at the time of the interview. Follow-up information on vital status was obtained for 643,001 (96 percent) of these respondents, with approximately 5.4 million person-years of follow-up.
Relationships between insurance status and subsequent mortality are examined using Cox proportional hazard survival analysis.
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 baseline (hazard ratio 1.03, 95 percent confidence interval [CI], 0.95-1.12). Omitting health status as a control variable increases the estimated hazard ratio to 1.10 (95 percent CI, 1.03-1.19). Also omitting smoking status and body mass index increases the hazard ratio to 1.20 (95 percent CI, 1.15-1.24). The estimated association between lack of insurance and mortality is not larger among disadvantaged subgroups; when the analysis is restricted to amenable causes of death; when the follow-up period is shortened (to increase the likelihood of comparing the continuously insured and continuously uninsured); and does not change after people turn 65 and gain Medicare coverage.
The Institute of Medicine's estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.

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    • "Similarly , our findings suggest that work debating about the rela - tionship between lack of health insurance and mortality is likely to be sensitive to attrition process by health insurance status , particularly for Mexican Ameri - cans ( McWilliams et al . 2004 ; Kronick 2009 ) . McWilliams et al . "
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    ABSTRACT: To compare models of attrition across race/ethnic groups of aging populations and discuss implications for health-related research. The Health and Retirement Study (1992-2008). A competing risks model was estimated using a multinomial logit model when respondents faced competing types of risks, such as dying, being lost from the study, and nonresponse in some years for different groups of elderly. Key explanatory variables were foreign birth, health insurance, and health status. Variables describing foreign birth, health insurance, and health status differed in their prediction of attrition across ethnic groups of aging populations. Differences in the predictors of attrition across ethnic groups of elderly could potentially lead to biased estimates in health-related research using longitudinal data sources.
    Health Services Research 09/2011; 47(1 Pt 1):241-54. DOI:10.1111/j.1475-6773.2011.01322.x · 2.78 Impact Factor
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    ABSTRACT: In contrast to a previous study we conducted and other evidence, a recent study found no significant effects of Medicare coverage after age 65 on overall health for previously uninsured adults and significant adverse effects on survival for some of these adults. We discuss explanations for these inconsistent findings, particularly the different ways in which deaths were handled, a key methodological challenge in longitudinal analyses of health. We demonstrate that analytic approaches suitable for examining effects of coverage on health measures may not be suitable for effects on mortality. Thus, estimates may be misleading when these different outcomes are jointly modeled. We also present new survival analyses that suggest Medicare coverage significantly attenuated the rising risk of death for previously uninsured adults.
    Health Services Research 03/2010; 45(5 Pt 1):1407-22; discussion 1423-9. DOI:10.1111/j.1475-6773.2010.01085.x · 2.78 Impact Factor
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