No Insurance? That’s a Killer.

Reading medical journals can be a real headache. Sure, the topics are important, but the demands of scientific accuracy make for dense, technical prose. The language is almost always an agony of arcane jargon and clunky grammar. Long, tangled sentences, heavy with terms like "multivariate analyses," are assembled to make small points. Research methods are explained in exhaustive detail, while conclusions are larded with caveats and qualifiers that pretty much render them inconclusive. It's the literary equivalent of wet cement.

Every now and then, however, you come across a statement that is the exact opposite of all that—a few simple words of plain English freighted with meaning. I encountered such a sentence in a study that appeared in the October issue of Archives of Surgery. Here it is: "In brief, insurance represents more than just the ability to pay a bill." That is as clean and concise a summation of a profound and complicated truth as I have come across since I first started paying attention to health-insurance issues more than a decade ago.

Of course, what insurance (and the lack of it) often represents, as numerous studies have shown, is the difference between care and no care, between an early cancer diagnosis and a late diagnosis, between properly managing a chronic condition like asthma and waiting until a dangerous attack occurs. For some of the patients in the Archives of Surgery study, which was led by Johns Hopkins trauma surgeon Adil Haider, what insurance represented was nothing less than the difference between life and death.

Drawing on the National Trauma Data Bank, which collects information from approximately 700 U.S. trauma centers and hospital emergency departments, Haider and his colleagues analyzed almost 430,000 moderate to severe cases of traumatic injury (from auto accidents, gunshots and other causes) treated between 2001 and 2005. Controlling for age, gender, type and severity of injury, they found that, overall, uninsured patients were 50 percent more likely to die from their injuries than insured patients. Among white patients, the mortality rate for those with insurance was 4.2 percent, compared with 7.9 percent for the uninsured. The numbers for minorities were worse. Uninsured African-Americans died at more than double the rate of the insured, 11.4 percent to 4.9 percent. And while 6.3 percent of insured Hispanic patients died after traumatic injury, the rate for uninsured Hispanics was 11.3 percent.

The study also uncovered dramatic differences in survival rates for patients of different races and insurance status. When compared with an insured white patient, black patients with equivalent injuries but without insurance had a 78 percent higher risk of dying; for uninsured Hispanics, the risk was 130 percent higher.

The findings by Haider and his colleagues erase any illusion that emergency care is the great equalizer in our health-care system, that our differences get left behind when we are rolled through those double doors, injured and in danger of dying.

Haider, who says that 60 percent of the patients he treats are uninsured, acknowledges that his study raises more questions than it answers. He can list possible reasons why the uninsured are more likely to die after trauma—they may have untreated underlying conditions due to a lack of routine care; they may delay seeking help after an injury—but knows more research is needed. One factor he is concerned about is the potential role of bias, conscious and unconscious. "We need to at least ask the question," he says. "Are we treating patients differently based on insurance status or race?" There's that plain English again.

© 2008