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


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.
    Full-text · Article · Sep 2011 · Health Services Research
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    ABSTRACT: When, exactly, did the debate become about "INSURANCE?" I don't give a damn about that. I want HEALTH CARE. The overriding goal of health reform is to provide every American affordable access to adequate health care. Yet in every national effort to date, the focal means to this end has always been health insurance. Massachusetts is congratulated for having achieved nearly universal insurance coverage, and congressional Democrats are aiming for the same. But what if they don't succeed? Even in Massachusetts, 167,000 residents remain uninsured. Is it still possible to provide adequate access to medical care for those without insurance? If so, shouldn't we reframe social goals to achieve universal access through any means possible, whether or not insurance is involved? The blog commenter and I agree that the answer to these questions is yes. This is not a technical or rhetorical point about a public option versus private plans. Instead, it is about insurance of any type as a funding mechanism versus direct government funding of providers to treat the uninsured. This contrast is essentially the same as that between "socialized insurance" and "socialized medicine." Even if we can't achieve "Medicare for all," perhaps we can achieve at least minimally acceptable access—something along the lines of "veterans' health for all." One way to characterize this alternative vision is as an adequate "safety net"—the accepted term for the conglomeration of hospitals, clinics, and doctors willing to accept patients regardless of ability to pay. Volumes of work document the inadequacies of safety net structure, funding, and access, but I have found many examples of safety net systems that function well enough. Much of the safety net is tattered and torn. Usually, it consists of a disconnected assortment of providers with limited funding and varied missions, willing to accept some patients in fairly dire straits as a last resort. Examples include underfunded public hospitals, thinly staffed free clinics, and overcrowded hospital emergency rooms. But in some places, the picture is quite different: state and local government agencies, charitable hospitals, physician organizations, or community groups have marshaled resources to organize well-structured systems of fairly comprehensive access for low-income, uninsured patients. Funding and motivation vary widely. Public and private hospitals seek to ease the burden on emergency rooms. Federal agencies and charitable foundations provide grants to build community networks and health facility infrastructures that will address disparities and lessen the greatest need. Local medical societies feel an ethical tug to facilitate physicians donating more indigent care. A variety of funding and delivery structures has emerged in places as diverse as San Francisco and San Antonio; Exeter, New Hampshire, and Asheville, North Carolina; Denver and D.C.; Flint, Michigan, and Richmond, Virginia. Some are completely free, and others charge substantial sliding-scale fees. Some are run by hospitals, others by physicians, and still others by community groups or local government. What these diverse safety net models have in common is simply affordable access to comprehensive health care. Covered services typically include a primary care medical home, essential medications, referrals to most specialists, and hospitalization. Recipients are screened for eligibility and given an enrollment identification that functions like (but is expressly not) an insurance card. If well-woven safety nets look and feel like insurance, are they really that different? The answer is yes and no—but before harping on the differences, let's be clear about why they matter. The differences matter ethically because safety net care, even at its best, is still inferior to the best insurance. But, economically, safety net care is affordable. Even at its best, it's still substantially cheaper than comprehensive insurance—cheap enough that it might just be possible to fund everyone who lacks insurance. The Veterans Health Administration system, for instance, which functions in many ways like a government-funded safety net, delivers care at 20 percent less than what it would cost at Medicare rates, which themselves are a quarter to a third less than private insurance rates. Economy is achieved through both the conceptual and operational differences between insurance and safety net access. Conceptually, a...
    Preview · Article · Nov 2009 · The Hastings Center Report
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