Health Care Reform on Life Support

People are dying for lack of insurance

By Eli Braun

Twelve-year-old Deamonte Driver died of an abscessed tooth that a routine $80 tooth extraction could have prevented. His family lacked health insurance and could not afford to pay a dentist. So they waited, thinking they had time for a toothache. While the toothache festered, bacteria from the abscess spread to Deamonte’s brain. The boy was hospitalized. Then, after two operations, six weeks of hospital care, and $250,000 in bills, he died.

Was the cause of death a tooth abscess, or was it lack of health insurance?

It has been well documented that people without health insurance face poorer health prospects. Why? Perhaps they engage in riskier behavior, smoke more cigarettes, or eat more junk food? Or, as a growing body of evidence suggests, uninsured people face poorer health prospects simply because they are uninsured. For decades, covering the uninsured has been a central goal of health-care reform. While the current bill in Congress delights neither the left nor the right, it represents the best chance in years to achieve this goal. If it dies, so will thousands of Americans.

U.S. Rep. John Boehner (R-OH) is Dr. No on health reform. REUTERS/Yuri Gripas.

‘Enough to make you sick’

What happens when sick people don’t have health insurance?

In a study of people with appendicitis, uninsured people were 18 percent more likely to suffer a burst appendix than those with private insurance. Researchers found that the people whose appendices burst tended to have waited longer before seeking medical attention. In fact, the delay in seeking medical care was “the most important predictor” of rupture.

These individuals waited because they could not access “primary and hospital care without cost concerns.” That is, people who were uninsured waited. Insurance status was the most important predictor even after researchers controlled for age, sex, socioeconomic status and hospital type.

As with Deamonte Driver, whose $80 barrier led to a $250,000 bill, delaying timely medical care has expensive repercussions. An appendicitis operation leads to a longer hospital stay and a larger bill if the appendix has burst.

Insurance status affects the prognosis of people with ailments besides tooth abscesses and appendicitis. Uninsured people are also more likely to be diagnosed with late-stage cancer. Consequently, uninsured people with cancer were almost twice (1.6 times) as likely as insured people to die within five years.

“The truth is that our national reluctance to face these facts is condemning thousands of people to die from cancer each year,” wrote Elmer Huerta, president of the American Cancer Society, in an editorial that accompanied the study. “For too many hardworking ‘average Americans,’ paying for cancer treatment means not paying rent, mortgage (resulting in foreclosure or eviction), or utility bills, or even going hungry.”

The American College of Physicians tracked similar evidence in its 2000 report, No Health Insurance? It’s Enough to Make You Sick. In 2002, the Institute of Medicine calculated that 18,000 uninsured adults died each year because, lacking insurance, they do not seek medical care. The Urban Institute estimated that between 2000 and 2006, 137,000 people died who would still be alive if only they had had health insurance.

The most recent estimate in 2009 found that nearly 45,000 people die in the United States each year – one person every 12 minutes – because they lack health insurance and cannot access medical care.

“We’re losing more Americans every day because of inaction … than [because of] drunk driving and homicide combined,” said study author David Himmelstein in an interview with Reuters. Himmelstein, a professor at Harvard Medical School, favors extending Medicare to all.

People without health insurance have more to worry about than just death.

Uninsured people with diabetes are at greater risk of blindness and amputations, according to the Institute of Medicine, which found that one in four uninsured adult diabetics go two years without a doctor’s visit, compared to one in 20 insured adult diabetics.

Too little, too expensive

More than 46 million U.S. residents, 15.4 percent of the population, were uninsured in 2008, according to the U.S. Census Bureau. One in 10 children – 7.3 million – were uninsured. Only people who lacked insurance for the entire year are counted as uninsured in the Census Bureau’s methodology, so these numbers might understate the true number of uninsured Americans. If you count people who were uninsured for at least one month in 2006-07, then 86.7 million Americans, comprising one in three Americans under the age of 65, had limited access to medical care.

The numbers vary by geographic region. In 2007-08, Texas had the largest percentage of uninsured residents (25 percent) while Massachusetts had the smallest (5 percent). Ohio ranked toward the middle, with 12 percent of its population uninsured. That’s one in eight Ohioans, or a million people total.

The current health-care reform bill, despite its faults, would reduce the number of uninsured Americans, according to the non-partisan Congressional Budget Office. It would provide subsidies for poorer Americans, expand Medicaid eligibility to 150 percent of the federal poverty level (133 percent in the Senate version) and institute various reforms to slow health care’s rising costs.

Rising health-care costs are partly responsible for the number of uninsured Americans. Between 2001 and 2007, insurance premiums rose 78 percent while wages rose only 19 percent. And as health-care costs rise, employers drop benefits. The Census Bureau found that the percentage of Americans who receive health insurance through their employers has decreased from 64 percent in 2000 to 59 percent in 2008. For many people, employment comes with fewer benefits.

In fact, one in six full-time workers, or 21 million people, were uninsured for the entirety of 2008, meaning that 45 percent of uninsured people actually worked full-time.

The current bill in Congress does more than cover the uninsured. It would prevent insurance companies from excluding people with pre-existing conditions. That would address one flaw of the current health-care system. Insurance companies cherry-pick customers, prioritizing profit at the expense of the sickest.

The bill does not, however, change the for-profit model of the American insurance industry. Even if this bill passes, companies can continue to minimize payouts and require higher co-pays. Medical bills are a frequent cause of bankruptcy, some critics note, and insurance is not serving its purpose if an illness can wipe out the family savings.

Despite the weaknesses of the existing health care system, the public appears reluctant to tinker with it. A poll conducted by the Health Foundation of Greater Cincinnati found that likely-insured Ohioans believed that the proposed changes go too far. Insured people comprise the vast majority of voters, which perhaps explains why health-care reformers have been so modest in their approach.

Not surprisingly, according to the Health Foundation poll, Ohioans who were likely to be uninsured thought the proposed changes don’t go far enough.

People with health insurance have better access to health care and better outcomes. Critics of health-care reform sometimes quip that uninsured people can always go to an emergency room. And yes, the 1986 Emergency Medical Treatment and Active Labor Act guarantees access for everyone to emergency services.

But many health conditions are chronic and require routine attention. Emergency-room care is too little, too late and too expensive. It can hardly be called satisfactory care for a patient with late-term cancer or a ruptured appendix. It did not save Deamonte Driver, and it can’t prevent another.

Health care reform might still pass Congress this year. But for the 45,000 people who died last year for lack of health insurance – or at that rate, the 123 people who died today – it’s already too late.