WASHINGTON, DC—Every year, 18,000 Americans aged 25 to 64 die prematurely because they have no health insurance. That is the conclusion of a new report from a committee of the Institute of Medicine (IOM). The report, “Care Without Coverage: Too Little, Too Late,” the second in an ongoing IOM series of six on the consequences of not having health insurance, was released at a news briefing here.
Committee members expressed surprise at the magnitude of harmful effects of going without health insurance. Cancer patients without insurance are especially hard hit.
“Uninsured cancer patients are generally in poorer health and they are more likely to die prematurely than are persons with health insurance, largely because of delayed diagnosis,” said Mary Sue Coleman, PhD, the IOM committee co-chair, a biochemist and cancer researcher who recently became the President of the University of Michigan after serving as President of the University of Iowa and Iowa Health System since 1995.
“For example, uninsured women with breast cancer have a 30% to 50% higher risk of dying than women with private health insurance. Uninsured patients with colon cancer have a 50% to 60% higher mortality rate than those with private health insurance.”
The other co-chair was Arthur L. Kellermann, MD, Professor and Chairman of the Department of Emergency Medicine and Director of the Center for Injury Control at Emory University School of Medicine.
In a subset analysis, the IOM committee calculated that of the 40,000 women who die annually of breast cancer, 360 to 600 are excess deaths that could have been prevented if these women had had regular medical care through health insurance coverage.
And Committee members called this a conservative estimate, saying that the figures for older age groups are much higher. The Committee—which examined more than 130 research studies—cited one study from the Centers for Disease Control and Prevention estimating that 30 percent of breast cancer deaths, about 13,000 annually, could be prevented if women age 50 and older received regular mammograms. This estimate is based on the fact that 80 percent of breast cancers occur in women over age 50.
The Committee also found studies concluding that uninsured patients are more likely to die prematurely—largely because of delayed diagnosis—from cervical, colorectal, and prostate cancers and from melanoma.
There are an estimated 40 million Americans without health insurance. This IOM report focused primarily on the 30 million working Americans without insurance.
As the first IOM report in the series pointed out, the majority of those without health insurance are the “working poor.” Dr. Coleman said that eight out of 10 uninsured people in the United States are working. Many of these are in low-paying jobs that do not provide insurance, or that require a co-payment that is too high for many employees. Even if they work two jobs, as many do, it is hard for these workers to pay for health insurance out-of-pocket.
‘Episodic, Disjointed Care’
Americans without health insurance have “episodic” and “disjointed” care, said Committee member Reed V. Tuckson, MD, Senior Vice President of Consumer Health and Medical Care Advancement for UnitedHealth Group in Minnesota, former Commissioner of Public Health for the District of Columbia.
Episodic care does not foster a regular relationship with a physician, having recommended screening tests such as mammograms or colorectal examinations, or becoming informed about healthy lifestyles, noted Dr. Tuckson. “There is an absence of continuity of care.”
Emergency departments, where many of the sick uninsured end up, are assuredly not the answer, noted Committee member John Z. Ayanian, MD, Associate Professor of Medicine and Health Care Policy in the Department of Health Care Policy at Harvard Medical School.
“Emergency departments are not equipped to diagnose people early or treat chronic illness,” he said. They can stabilize a patient and treat a broken bone, but they don't screen for illnesses such as cancer.
“Not only is it expensive, but it is also not the best care for chronic conditions,” concurred Committee member Edward H. Wagner, MD, Director of the W.A. MacColl Institute for Healthcare Innovation at the Center for Health Studies of Group Health Cooperative in Seattle.
One of the report's most disturbing findings related to cancer is that in studies assessing the outcomes for adults with cancer—stage of disease at diagnosis and mortality—people insured under Medicaid often did no better (and sometimes even worse) than uninsured patients.
The IOM Committee concluded that this finding may reflect the fact that uninsured people in poor health, once they seek care, may become enrolled in Medicaid—in effect enrolling too late to have much of an impact on a growing and previously undiagnosed cancer.
Dr. Tuckson emphasized that the Committee's findings show that health insurance has to be acquired early, before people become ill, and that they need to obtain a full range of health services on a continuous, coordinated basis. He said this new IOM report should convince members of the general public—-if they still have doubts—that health insurance does, in fact, make a huge difference in health outcomes.
“This is a major American problem,” Dr. Tuckson said. “It is a tragedy of numbers.
Another disturbing finding of this report is that Americans without health insurance are treated differently in the hospital from those who have insurance.
The Committee said uninsured hospitalized patients “experience higher rates of death in the hospital, receive fewer services, and are more likely to experience an adverse medical event due to negligence than are insured patients.”
Committee members expressed surprise at the magnitude of harmful effects of going without health insurance.
Dr. Ayanian said insurance is a “major factor” when a person enters a hospital. Asked if there is a two-tiered system of care in hospitals, he said that people without insurance “are receiving a lower intensity of care.”
The committee found that people who had no insurance or temporarily lost it for a period of one to four years suffered a decline in overall well-being, and that a loss of coverage is most profound for older adults between ages 55 and 65 who are not yet eligible for Medicare.
“Short periods of going without insurance can make a difference, but longer periods are even more harmful,” said Dr. Ayanian.
The IOM Committee's final report in this study series of six will focus on promising strategies for addressing the problem of the uninsured in the United States. The six-report IOM study on uninsured Americans is being funded by the Robert Wood Johnson Foundation.
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Cancer-Related Findings from the Report
Cancer patients without health insurance die sooner on average than those with insurance, mostly due to delayed diagnosis.
- This finding is based on population studies of patients with breast, cervical, colorectal, and prostate cancers, and melanoma.
Uninsured patients with breast, colorectal, or prostate cancer are more likely to die prematurely from their disease than are patients with private health insurance.
- Uninsured women with breast cancer have a risk of dying that is 30–50% higher than the risk for women with private health insurance.
- Uninsured patients with colorectal cancer are about 50% more likely to die than are patients with private insurance, even when the cancer is diagnosed at a similar stage, according to cancer registry data.
Uninsured adults with cancer might have differences in treatment.
- Uninsured women with breast cancer are less likely than privately insured women to receive breast-conserving surgery.
- Disparities in treatment persist among racial and ethnic groups even if all have insurance, however.
Source: Institute of Medicine, Committee on the Consequences of Uninsurance, Board of Health Care Services, National Academy Press, 5/02.