Monday, December 21, 2009

How Many Really Died?

The Urban Institute issued a report last year stating that hundreds of thousand were dying in the US because they had no health care. In the report they contend:

"In 2002, the Institute of Medicine (IOM) estimated that 18,000 Americans died in 2000 because they were uninsured. Since then, the number of uninsured has grown. Based on the IOM's methodology and subsequent Census Bureau estimates of insurance coverage, 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006."

The essence of the Urban Report analysis was a simple formula:

DT=(PI x X) + (PU x X x 1.25)

where DT is the total deaths in some group, and X is the percent in a group dying if they were insured and PI is the number in the group insured and PU the number uninsured. The report assumes that the death rate for the uninsured is 25% greater than insured no matter what. The report then spends pages using the formula for every possible variation under the sun. The key question is where did the 25% come from?

The answer one would guess is from the Institute of Medicine Report, IOM, Care Without Coverage, 2002. That report contends that the reasons are due to:

1. Primary Prevention and Screening Services

Uninsured adults are less likely than insured adults to receive recommended health screening services (e.g., mammograms, clinical breast exams, Pap tests, colorectal screenings). And when they do receive these preventive services, it is not as often as recommended by the U.S. Preventive Services Task Force. The disparities in whether someone uses these vital services holds even after accounting for the possible influence of age, race, education or having a regular source of care.

2. Cancer Care and Outcomes

Uninsured cancer patients generally have poorer outcomes and die sooner than persons with insurance. Without timely preventive screenings, diagnosis is delayed. As a result, when cancer is found, it is relatively advanced and more often fatal than it is in persons with health insurance coverage. For example, uninsured women with breast cancer have a 30 to 50 percent higher risk of dying than women with private health insurance. Furthermore, once diagnosed, treatment
disparities persist. For example, uninsured women are less likely to receive breast-conserving surgery.

3. Chronic Disease Care and Outcomes

Uninsured adults are less likely to have regular checkups and a usual source of care to help manage their disease than is a person with coverage. For the five chronic conditions that the Committee examined (diabetes, cardiovascular disease, end-stage renal disease, HIV infection and mental illness), uninsured patients have worse clinical outcomes than insured patients.

3.1 Diabetes: Uninsured adults with diabetes are less likely than those insured to receive the professionally recommended standard of care for monitoring blood glucose levels and other complications. Uncontrolled blood glucose levels puts persons with diabetes at increased risk of hospitalization and additional complications

3.2 Cardiovascular Disease: Despite the fact that having a usual source of care improves medical management, 19 percent of uninsured adults diagnosed with heart disease and 13 percent with hypertension lack this ongoing relationship

3.3 End-Stage Renal Disease (ESRD): The clinical goals for treatment of kidney disease are to slow the progression of renal failure, and prevent or manage complications and co-existing diseases

3.4 Human Immunodeficiency Virus (HIV) Infection: One positive effect of health
insurance for HIV-infected adults is obtaining a regular source of care. Without health insurance, many wait more than three months after diagnosis to have their first office visit.

3.5 Mental Illness: Mental illness represents a major but often underestimated source of disability. It contributes as much to disability as does cancer or heart disease. As is the case with other diseases, the uninsured are less likely than those with coverage to receive the desirable level of mental health care.

Let us examine these causes.

First, preventive screening does help. One of the problems with those having no insurance is also a reluctance to seek medical advice and the primary reason often is fear of finding out that one is ill. Frequently there is the hiding effect, namely if I do not check out the problem it will go away. It may not be the problem of there being no care available. Many clinics provide mammograms for example, yet the fear is if it is positive then what? There are also significant cultural fears as well. In effect fear and cultural predispositions may dominate on the outcome and not just lack of insurance.

Second the cancer care outcomes seems highly unjustified. True those with resources will seek out say Memorial Sloan Kettering rather than just their local surgeon. That is a resource driven solution as well as a family support one. On the other extreme one often sees in lower income families the demand to keep a person alive at all costs where in more well off families there are advance directives! In effect there are many forces at play and the blank assertion made is problematic at best!

Third, the chronic diseases are for the most part self inflicted. Diabetes and its sequellae, including renal failure, caused mainly by Type 2 Diabetes, are personal choices. As reported this week in Science:

"Nation of Flab

Obesity is edging ahead of smoking as a health hazard in the United States, say researchers at the National Bureau of Economic Research in Cambridge, Massachusetts. A team led by Susan Stewart, a researcher who studies aging, has come up with some hard numbers on the skyrocketing problem: In the past 15 years, smoking has decreased by 20%, but the number of fat Americans has increased by 48%. By 2020, the team calculates that obesity will rob an 18-year-old of 0.7 years of life on average and 0.9 years of "quality of life." The average gain for an individual from not smoking—0.3 years—is more than offset by the loss of more than a year from weight gain, the authors reported last week in The New England Journal of Medicine. Even if obesity increases level off to as little as 0.15% per year, they'll swamp overall gains from nonsmoking by 2020."

And yes, the obesity problem is highest in the lowest income groups and in the uninsured. Thus this self inflicted disease and resulting costs are due to choice and not failure to have insurance. It is in fact the providing of food stamps used for the purchase of high carb food which drives this effect.

Thus the problems in 3.1 through 3.4 are for the most part self inflicted. As for mental illness, it is often covered by Medicaid and its problems are the result of the changes to health care since the 1960s when most mentally ill were released to live on their own. I am not objecting to that but stating that the decision had costs.

Thus the IOM report has I believe many deficiencies. It failed to look at the totality of causality. It looked at best at some data and jumped to a conclusion. It did not holistically look at a complex system which has problems and at people who have responsibilities. For example should we have to pay for the costs of a three pack a day smoker? Probably not. How does an economy solve that? Tax the cigarettes and keep the money separate for payment of resulting costs. Simple, but Congress would never do that. They would spend the money and then complain.

The problem with IOM type reports, having been on many such a committee, is that all too often they are written by staff with minor input by the group. The group at best meets periodically and all have "day jobs". This is a systems problem and it will become a more costly problem as we expand health care. It demands s systematic study with facts not just assertions.