Health Coverage Not Clearly Related to Mortality


Lack of health coverage is said to kill, but there is surprisingly little evidence to support this claim, writes Linda Gorman in the fall issue of the Journal of American Physicians and Surgeons.

The 2002 Institute of Medicine (IOM) report Care without Coverage: Too Little, Too Late asserted that 18,000 Americans died each year because they lacked health coverage. The report did not discuss whether mortality rate differences were caused by a lack of health insurance or by behaviors known to damage health and more likely to occur in groups of people who are uninsured.

An in-depth 2009 study found that the IOM estimate was “almost certainly incorrect.” Those who said that they were uninsured were in higher risk groups by almost every characteristic that was measured. After adjusting for differences in risk profiles unrelated to insurance coverage, mortality for uninsured respondents was no different than that of those covered by employer-sponsored group insurance.

A commonly cited 2012 report by Sommers and associates claims that mortality fell more in the early 2000s in states that expanded Medicaid than in those that did not. Results mostly depended on New York, which had higher mortality just before the expansion because of the World Trade Center disaster and a high prevalence of human immunodeficiency virus (HIV) infection, and lower afterward because of better treatment for HIV. One cannot attribute the difference to Medicaid expansion without correcting for these factors, which were not considered by Sommers.

“Studies that correct for possible behavioral and demographic differences between the insured and uninsured are less likely to show that health coverage reduces mortality,” Gorman writes. “Those that do show mortality reduction have been more likely to make unrealistic assumptions about the underlying data or to ignore significant differences in the groups being compared.”

Hence, she concludes, “expanding health coverage further might have a relatively small effect on mortality, one that might be mostly attributable to differences in the groups under study.”

The Journal is the official, peer-reviewed publication of the Association of American Physicians and Surgeons (AAPS), a national organization representing physicians in all specialties, founded in 1943 to preserve private medicine and the patient-physician relationship.

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