45000 without insurance die?

I often see the proclamation that 45 thousand people die every year because they don’t have health insurance. This number comes from a Harvard study, so it is pronounced with great reverence and seldom questioned or considered. The study is widely available on the internet, and I suggest you read it. While reading it consider the point-of-view of one of the authors: according to the NIH website "Dr. Stephanie Woolhandler helped found Physicians for a National Health Program, a not-for-profit organization for physicians, medical students, and other health care professionals who advocate a national health insurance program."

Of course, the number quoted is the highest number in the study, and comes about only when using criteria suggested by the Urban Institute. The lower end of the estimated range is 27424, or a just about 50% less, albeit this covers only ages 25-64. Ignoring the Urban Institutes guidelines, the number provided is 35327 deaths annually for the non-elderly (ages 18-64), compared to the larger number 44789.

But the study also had several severe limitations.

First, the study relied on self-reported insurance status (unverified data). Further, the study only included insurance status at a single point in time, without determining whether the participants were actually insured at the time of their death. If a person had not been insured at the time of the initial interview, but got insurance later in the 6-year study period and may have actually had insurance at the time of death, they were counted as if a lack of insurance had contributed to their death. The authors have no information as to the duration of insurance coverage or lack thereof--only that the person was uninsured during the initial interview. To be fair, it may also be true that some people who reported having private insurance later dropped or lost their insurance, but the study does not consider either case.

Next, the study made no effort to determine that the cause of death was related to health insurance status. Deaths due to auto accidents, homicides, etc. were counted the same as deaths due to untreated diabetes. This is made more problematic because the study oversampled blacks and blacks are six times more likely to be victims of homicide than whites.

The study also excluded people on Medicare, which is reasonable as the study focused on the non-elderly. However, the study also excluded "nonelderly Medicare recipients and persons covered by Medicaid and the Department of Veterans Affairs/Civilian Health and Medical Program of the Uniformed Services military insurance, as a substantial proportion of those individuals had poor health status as a prerequisite for coverage." These people were excluded because they were probably already sick and the fact that they had health care coverage, albeit government supplied, would likely have skewed the results. If they had died during the study, the hypothesis that lack of coverage is associated with increased likelihood of death may have been less strongly supported; also, it may well have indicated that having government-provided coverage is even more strongly associated with increased likelihood of death.

Although the study seemed to indicate that “uninsurance is associated with mortality,” it also points out that “uninsurance was associated with younger age, minority race/ethnicity, unemployment, smoking, exercise, self-rated health, and lower levels of education and income. Regular alcohol use and physician-rated health were also associated with higher rates of uninsurance.” Or, as the authors put it “unmeasured characteristics (i.e., that individuals who place less value on health eschew both health insurance and healthy behaviors) might offer an alternative explanation for our findings.”

Finally, it is worth noting that of all those who were included in the study, a total of 3.1% died. Of those who died, 83.8% had private insurance (but still died). The overall rate of death was 3.0% for the privately insured, and 3.3% for the uninsured. So, 97% of the privately insured were still alive after the study period ended, and so were 96.7% of uninsured.

In other words, there may be a 0.3% increased chance of death associated with instances of unverified periods of uninsurance (of unknown duration) and where cause of death may or may not be related to health-care related factors.

By way of comparison, in 2008 there were 43,313 deaths in auto accidents in the U.S. That number is typical for the annual loss of life on our roads. Each of those deaths was 100% preventable by simply banning automobiles. We could save many of them by simply lowering the speed limit to 25MPH on all roads. Are we willing to spend $1T to save those people over the next 10 years?

For further comparison, the CDC says that approximately 90,000 people die each year as a result of acquiring an infection while in a hospital. Almost all of those deaths could be avoided if doctors, nurses, and other hospital staff would simply wash their hands and use hand sanitizers regularly and properly.

P.S. According to the numbers in the Harvard report, being male had almost the exact same “risk” as being uninsured.