A Project of The Annenberg Public Policy Center

Dying from Lack of Insurance

A new study from researchers with the Harvard Medical School found that 45,000 deaths a year can be attributed to the lack of health insurance. Our readers ask: Really? And, they want to know, isn’t this finding actually from the single-payer advocacy group Physicians for a National Health Program?

We’ll answer the latter first: The study was conducted by six researchers who were all with the Department of Medicine at Cambridge Health Alliance, which is affiliated with Harvard Medical School. It was published by the American Journal of Public Health, a peer-reviewed journal. Lead author Dr. Andrew P. Wilper is now with the University of Washington Medical School. As for PNHP, two of the authors have strong connections with the group: Dr. Steffie Woolhandler and Dr. David Himmelstein, a professor and associate professor of medicine, respectively, at Harvard Medical School, are co-founders of PNHP, a group of physicians that advocates for a single-payer health care system.

PNHP publicized the results of the study. Harvard, too, touted the research. Dr. Woolhandler told us that PNHP didn’t have anything to do with the study other than publicizing it after it was released. PNHP "didn’t fund it … didn’t have anything to do with analysis," she says.

The 45,000 deaths figure became the basis for an eye-catching billboard from the Health Care for America Education Fund, a group associated with Health Care for America NOW, a coalition of liberal and union groups backing health care overhaul efforts.

Now, on to the tough question: Is the 45,000 figure accurate? We can’t say for sure, but scores of other studies also conclude that persons without health insurance have a higher chance of dying prematurely than those with health insurance. A committee headed by Dr. John Z. Ayanian of the National Academies’ Institute of Medicine reviewed nearly 100 such studies released since 2002. And in March he summed up the findings for Congress this way: 

Ayanian’s testimony to Congress, March 2009: Uninsured Americans frequently delay or forgo doctors’ visits, prescription medications, and other effective treatments, even when they have serious disease or life-threatening conditions. … Because uninsured adults seek health care less often than insured adults, they are often unaware of health problems such as high blood pressure, high cholesterol, or early-stage cancer. Uninsured adults are also much less likely to receive vaccinations, cancer screening services such as mammography and colonoscopy, and other effective preventive services.

The 45,000 estimate is at the high end of estimates, but earlier studies also have put the number of excess deaths from lack of insurance coverage in the thousands:

  • A 1993 examination of 1971 through 1987 data on 25- to 74-year-olds from the National Health and Nutrition Examination Survey found a 25 percent higher risk of mortality for the uninsured compared with the insured, after adjusting for various factors, such as age, smoking, alcohol consumption, obesity, education and income. The study, by lead researcher Peter Franks, was published in the Journal of the American Medical Association.
  • In 2002, the Institute of Medicine, basing its work on the Franks study and another examining Current Population Survey data, found that 18,000 people (age 25 to 64) died because they lacked health insurance in 2000. (Ayanian added in his testimony that for those with heart disease or cancer and without health insurance, the risk of death for the uninsured could be 40 percent to 50 percent higher.)
  • In 2008, the Urban Institute updated the IOM numbers, using later Census Bureau estimates on the uninsured. It found that in 2006, the number who died because of a lack of insurance was 22,000. The Urban Institute also said that the IOM figure "may have underestimated the number of deaths" by trying to calculate different mortality-rate differences for each age group, an approach the Urban Institute said wasn’t well grounded in the research. Applying a mortality-rate difference to the entire population under study produced an even higher number, 27,000.
  • The latest report by Harvard researchers used the methodology of IOM but more recent data. It found that the uninsured are 40 percent more likely to die prematurely. And it expanded the age group a bit, estimating that among adults age 18 to 64, there were 35,327 deaths linked to a lack of insurance in 2005. Calculating the estimate without a breakdown by age group increased the figure to 44,789.
  • A 2007 report published in the Journal of General Internal Medicine examined data for adults age 45 to 64 from the Atherosclerosis Risk in Communities Study, sponsored by the National Heart, Lung and Blood Institute, finding that the uninsured had a 26 percent higher mortality.
  • A 2004 study published in the journal Health Affairs looked at data for those age 55 to 64 in the Health and Retirement Survey. It controlled for socioeconomic factors and found the uninsured in the group had a 3 percent higher risk of dying over an eight-year period. The study called uninsurance the third leading cause of death for that age group, saying that more than 13,000 yearly deaths "may be attributable to the present lack of insurance coverage among the near-elderly."

As we recently reported, the American Cancer Society also found lower survival rates for colorectal cancer among the uninsured compared with the privately insured.

There has been some criticism of this type of research and its ability to find a direct causal link. A 2003 commentary by Richard Kronick in Medical Care Research and Review questioned whether other factors beyond uninsurance would reduce the greater mortality for the uninsured. Kronick recreated the Franks study using more recent data and, after adjusting for various factors, also found a 25 percent greater risk of death for the uninsured. But he said: "It seems likely that if we were able to control for additional factors, such as health-related behaviors (smoking, alcohol consumption, obesity, and risk-taking behaviors more generally), wealth, or value placed on health or health care, the estimated effect of being uninsured would be reduced further. What is uncertain is whether the reduction would bring the estimated hazard ratio all the way down to 1.0 or whether an independent effect of being uninsured would remain." (Other studies, including the Franks study, did adjust for smoking, alcohol consumption, obesity and income.)

Another recent report, written by former Congressional Budget Office Director June O’Neill and her husband, economist Dave O’Neill, said "that lack of health insurance is not likely to be the major factor causing higher mortality rates among the uninsured. The uninsured — particularly the involuntarily uninsured — have multiple disadvantages that in themselves are associated with poor health." Those disadvantages include education level and income. The O’Neills’ study, published by the conservative Employment Policies Institute, separated those it deemed "voluntarily uninsured" (anyone earning 2.5 times the poverty level) from those considered to be "involuntarily uninsured." The study looked at data on persons aged 51 to 61 from the Health and Retirement Survey and determined the "involuntarily uninsured" had an 11 percent higher probability of dying; the number dropped to 3 percent when controlling for smoking as well as education and income. The “voluntarily uninsured” had a 2 percent to 3 percent greater probability of dying. EPI, the publisher of the study, supports business interests and has said that the “living wage campaign” is “an organized effort to force employees to inject a welfare mentality into the workplace.”

It’s important to remember that all of these studies give estimates based on modeling and data with limits. As the Urban Institute wrote: "At the most basic level, the above estimates are not precise ‘body counts.’ Rather, the reader should view them as reasonable indicators of the general magnitude of excess mortality that results from

The 45,000 Number

The Harvard report, finding 45,000 excess deaths linked to uninsurance, made news partly because it was so much larger than past estimates. Why the big difference between the Urban Institute/IOM numbers and the latest report? Dr. Woolhandler explains that the Harvard researchers aimed to replicate what IOM had done back in 2002 but with more recent data. Where IOM cited a 25 percent increase in mortality for the uninsured, the Harvard researches found a 40 percent increase. IOM based its examination on the Franks study’s 1971 through 1987 data on 25- to 74-year-olds from the National Health and Nutrition Examination Survey. The Harvard report looked at National Health and Nutrition Examination Survey data (collected by the National Center for Health Statistics) from 1988 through 1994, with a follow-up on whether participants lived or died through 2000.

She gives a few reasons for why uninsured deaths would have gone up over the years. She says that "relative to the insured, [being] uninsured has become more lethal." What that 40 percent figure shows is the difference between the death rate for the insured and the death rate for the uninsured. "We think medical care has gotten more effective, so that going without it puts you at a relative disadvantage," she says citing advances in care for leading causes of death including cardiovascular disease, cancer and stroke.

Also, the population and the number of uninsured have gone up in that time period. The study explains that researchers "controlled for tobacco and alcohol use, along with obesity and exercise habits." It also notes that this study has limitations. The data from the National Center for Health Statistics "assessed health insurance at a single point in time and did not validate self-reported insurance status. We were unable to measure the effect of gaining or losing coverage after the interview."

The Institute of Medicine’s Dr. Ayanian, however, did tell Congress that research shows gaining coverage makes a difference: "Fortunately, our Committee also found good news to report: when uninsured people acquire health insurance they can experience both immediate and long-term improvements in their health."