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Uninsurance is a fatal disease

When General Assistance Medical Care (GAMC) ends in July of 2010, approximately 36,000 Minnesotans will join the ranks of the uninsured. While much has been said about what this might mean for Minnesota's safety net hospitals and clinics as the number of uninsured Minnesotans swells to more than 400,000 people still needing health care, not enough has been said about the health diagnosis for those who find themselves uninsured.

The loss of insurance does not merely cause patients to experience the inconvenience of longer lines in public hospitals or community-clinic waiting rooms to see a doctor. No! Lack of insurance is a real disease and, as it turns out, a potentially fatal one.

The uninsured are a well-studied but misunderstood group. In the United States there are an estimated 47 million uninsured and, contrary to common belief, undocumented or newly arrived immigrants compose only a small fraction of this number. The uninsured are not elderly; typically they are under the age of 40. More than 80 percent of the uninsured are from working families, and 20 percent — or nearly 8.7 million of the uninsured — are children.

Much has been written about the increasing number of uninsured, their demographics, the reasons for uninsurance and the cost of providing universal coverage. Little has been published about the health consequences of being uninsured. It's a fact that uninsured people are sicker, span a wide range of ages under 65, have worse health status and die younger. 

Lack of insurance leads to excess death rate
The prestigious Institute of Medicine, in its landmark 2002 report, estimated that 18,000 United States residents die each year because they lack insurance. Two longitudinal studies cited in the report estimate the uninsured have a 25 percent higher risk of death and are 3.2 times more likely to die in the hospital than the insured. This excess death rate does not respect gender, age or disease state.

Uninsured women with breast cancer have a 35-57 percent higher adjusted risk of death compared to insured women. Uninsured pregnant women have a 31 percent higher chance of an adverse hospital outcome, including infant death after giving birth. Uninsured diabetics are 11 times more likely to experience avoidable hospitalization.

A 2004 study from the Harvard Medical School faculty estimated the risk of death in the uninsured "near elderly" is a risk-adjusted 43 percent higher than age-matched insured; they have a 53 percent increase in premature deaths. This results in more than 100,000 premature excess deaths over an eight-year period in the 50-64 age group alone, attributable solely to lack of health insurance. Not surprisingly, patients with high blood pressure, diabetes, or heart disease were most affected.

The excess mortality seen in the uninsured is not only due to lack of screening, patient inability to afford prescription drugs or ability or lack of willingness to seek preventive care. A 2003 study from the Massachusetts Institute of Technology looked at an unplanned medical event: auto accidents. This study amazingly found that the uninsured receive 20 percent less overall treatment for their condition and are 37 percent more likely to die of their injuries than those with insurance.

Recent studies updating the 2002 Institute of Medicine report suggest that the annual number of excess premature deaths due to uninsurance is now 22,000 deaths per year, resulting in a total of 137,000 premature unnecessary deaths from 2002-2006.

Boomers will increase premature excess deaths
Aging baby boomers will increase the premature excess deaths greatly in the future and will result in 30,000 excess and unnecessary deaths in the near elderly each year by 2015. Therefore if the mere lack of insurance (uninsurance) were categorized as a disease it would be the third leading cause of death in the near elderly behind heart disease and cancer.

No doubt, health insurance saves lives. The governor and Legislators need to directly address whose interests are served by increasing Minnesota's uninsured by 36,000 individual lives. It is time to realize that uninsurance is fatal. Sustaining this newly defined disease in the name of fiscal responsibility, tax-increase avoidance, or a balanced budget is unconscionable and unethical — and certainly poor public policy.

Michael Belzer, M.D., is medical director/chief medical officer of  Hennepin County Medical Center and associate dean of the University of Minnesota Medical School.

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Comments (8)

Well said. What is often lost in this debate about health care reform is the fact that as America declines internationally, in virtually every health category, so too do we weaken ourselves both literally and figuratively. As Dr. Belzer points out, this is not only an ethical issue, it to also goes straight to the vigor, vibrance, and physical robustness of our society.

No question, the uninsured are a concern, though perhaps it should less a concern than the cost of healthcare and the lack of tort reform that forces providers to engage in excessive, expensive, defensive care and testing which drives up the cost of insurance.

The fact remains, however, that the ranks of the uninsured are swelled by a significant number of young who are capable of buying insurance but choose not to because they prefer to spend their money in other discretionary ways.

If they participated in the commercial insurance pools, they wouldn't be as large a burden when they showed up in ERs and would contribute to the insurance pools lessening the the costs for all.

Government provided healthcare, state or federal, removes important market forces, even as those forces are severely perverted now by government regulations.

An ex-patriot Canadian doctor, practicing here in the metro, correctly notes that there are two ways that government sponsored heathcare (or insurance) reduces the cost of healthcare--buy reducing the amount of care and by reducing what they pay providers. And that's why there are more ex-pat Canadians doctors practicing in the U.S. than ex-pat U.S. doctors practicing in Canada.

This article leads one to ask the question: should we consider health care a commodity or a common good? If we see health care as a commodity, it makes sense to demand that we each purchase it separately and not let policy be driven by those who fall between the cracks (as another commenter advocates). If we see health care as part of the common good, like police and fire protection, we would make it available to ALL residents and pay together, probably according to ability to pay, as with many tax-supported services. Most of us are moving to the view that health care is part of the common good and so we need one system that covers everyone. Gubernatorial candidate John Marty proposes the Minnesota Health Plan as just such a solution (mnhealthplan.org) I think those of us who are moved by this article should check it out.

@Wilford,

"No question, the uninsured are a concern, though perhaps it should less a concern than the cost of healthcare and the lack of tort reform that forces providers to engage in excessive, expensive, defensive care and testing which drives up the cost of insurance."

Of course, because the inconvenience of a corporation being held accountable in a court of law is much worse than dying for lack of insurance.

"The fact remains, however, that the ranks of the uninsured are swelled by a significant number of young who are capable of buying insurance but choose not to because they prefer to spend their money in other discretionary ways."

No, the fact doesn't remain. This is a myth. I'm sure you an find someone stupid enough to forgo insurance when they don't have to, but how odd there are never enough to affect the statistics.

"Government provided healthcare, state or federal, removes important market forces, even as those forces are severely perverted now by government regulations."

Every other industrialized democracy gets by without these "important" market forces, and does much better than we do. The free market has had a century of private insurance to address the problems. Clearly private insurance can't address them. The market is the problem, not the solution.

And your doctor friend is wrong, there's a third way to reduce costs. Stop paying 25% administrative overhead which Medicare doesn't have, Canada doesn't have, and no one else has except US insurers.

Ah yes, the favorite right-wing talking point is to blame young workers who "could" get insurance but refuse to.

Yes, a young person can get health insurance for $66 a month in this area, but for someone just out of school who is working a $10 an hour job and paying off student loans, that's a significant amount of money. Besides, people that age tend to think that they're immortal, and in fact, the majority of them are pretty healthy, not yet subject to any degenerative or lifestyle diseases.

What I see in my fifty-something age group are many people who have been priced out of insurance. When you reach the big "5-0," the price of your insurance suddenly skyrockets, and it keeps going up every year with no increase in benefits. As a self-employed person, I have had to keep raising my deductible to be able to afford any kind of insurance at all. Currently, I have a $5000 deductible with a 20% copay after meeting the deductible. Even though I have never used up my deductible, my premiums have been gone up 10-15% every year. Another two years, and I may have to raise my deductible yet again, at which point you have to ask what good the coverage is, since even the out-of-pocket expenses for the next level of deductibles would send me into bankruptcy.

Many of my friends have decided that they'd rather take their chances than shell out hundreds of dollars per month of free money for the insurance company.

So knowing all the middle-aged people who are uninsured or under-insured, I get disgusted with all the smug right-wingers who tell me how wonderful America's health care system is.

A dental hygienist I know and her husband purchase insurance for themselves and their two children. Like many policies these days, the policy is a so-called low premium/high deductible one. The reality is that, after paying a good price for insurance but before the insurance company pays a penny in benefits, each person in the family must meet a $5,000 deductible each year.

Since their family has been fortunate enough not to have incurred $5,000 in expenses in any one year for any member, they are now unfortunate enough to have received zero payments for any expense from their insurance company for four years.

Driven between truly dedicated health care professionals such as Dr Belzer and his patients is something that is deeply out of place, out of place for what most people wish for health care - that thing out of place is profit.

It's not profit being driven at HCMC, as they are of course a not-for-profit institution. Does anyone remember HCMC in the mid-eighties, certainly not-for-profit..... the place is so much improved today it's impressive to see. Oh, and this turnaround done while creating a nationally recognized level I trauma center, WITH-OUT profit as the core motivator (a balanced budget maybe, but not profit).

And it's certainly not profit being driven TO the people seeking care at the facility, because they are of course paying, not collecting. The single mother earning $18k/yr bringing her kid in with a temp of 103.5 isn't thinking about profit - whether she's making it or supplying it. She, and her sick daughter, have a basic human right to receive care....and we (the State, the Country....the tax payer) have the ability provide to everone. Why is it so hard to do?

Profit.

It's the profit that is demanded by the folks who, in the article above, actually have the key to the cure, ....the Insurance Companies. The Deciders of the Uninsured (thru premiums that for many are unaffordable). So how can they provide the cure? - they can get the heck out of the way of a doctor trying to provide care for a kid in pain.

The levels of profit generated by massive insurance companies are simply embarrassing. The greed to drive premiums so high, so fast has created a national call for change, big change. It would be funny if it wasn't so serious. Funny because insurance companies have priced themselves out of the market. Serious because there is a kid in pain who could get turned away. What a waste of resources, OUR resources, at a time when those resources are so thin. Driven for insurance company profits. But reform, or better yet elimination, of health insurance (with a replacement of one system) is a longer-term issue. Health care should be considered a common good. The Governor will do a disservice to our community by cutting the budgets of places he shouldn't be cutting, places that deserve more respect and thoughtful consideration that what he is giving, places that provide for the common good.

The Governor should check his priorities.

The long-term issue is reform of the insurance companies, they are the ones that create the disease of uninsurance - without them we may actually find a cure to Dr Belzers newly defined disease. But until then, Mr Pawlenty, can you do the right thing and stop trimming at the edges of our safety net hospital so that kid can get some care?

There's nothing wrong with profit per se. At its best,it's a tremendous force for innovation. At its worst, it's a cause for revolution.

Mr. Clemmer asks whether we should consider health care a commodity or a common good. It can be both, as are the utilities we all use (and pay for) every day: electricity, gas, water, telephone service, etc. We regulate these and permit (virtually guarantee) a certain level of profit. Why not a similar approach to health care? We can't directly regulate individual provider charges, but we can do so indirectly by regulating health insurer profit levels, whether directly (as we do here in MN with nursing home rates) or indirectly (through tax rules).