Health Insurance Coverage and Mortality Revisited

Richard G. Kronick

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Healthcare Policy and Management Health disparities and outcomes Employment and Welfare Studies

Abstract

OBJECTIVE: To improve understanding of the relationship between lack of insurance and risk of subsequent mortality. DATA SOURCES: Adults who reported being uninsured or privately insured in the National Health Interview Survey from 1986 to 2000 were followed prospectively for mortality from initial interview through 2002. Baseline information was obtained on 672,526 respondents, age 18-64 at the time of the interview. Follow-up information on vital status was obtained for 643,001 (96 percent) of these respondents, with approximately 5.4 million person-years of follow-up. STUDY DESIGN: Relationships between insurance status and subsequent mortality are examined using Cox proportional hazard survival analysis. PRINCIPAL FINDINGS: Adjusted for demographic, health status, and health behavior characteristics, the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer-sponsored group insurance at baseline (hazard ratio 1.03, 95 percent confidence interval [CI], 0.95-1.12). Omitting health status as a control variable increases the estimated hazard ratio to 1.10 (95 percent CI, 1.03-1.19). Also omitting smoking status and body mass index increases the hazard ratio to 1.20 (95 percent CI, 1.15-1.24). The estimated association between lack of insurance and mortality is not larger among disadvantaged subgroups; when the analysis is restricted to amenable causes of death; when the follow-up period is shortened (to increase the likelihood of comparing the continuously insured and continuously uninsured); and does not change after people turn 65 and gain Medicare coverage. CONCLUSIONS: The Institute of Medicine's estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.

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References

2000Unmet Health Needs of Uninsured Adults in the United States 2008The Impact of Nearly Universal Insurance Coverage on Health Care Utilization: Evidence from Medicare 2003Sicker and Poorer—The Consequences of Being Uninsured: A Review of the Research on the Relationship between Health Insurance, Medical Care Use, Health, Work, and Income 2009Does Medicare Save Lives? *2005Care without Coverage: Too Little, Too Late 1993Health Insurance and Mortality 2008Is American Health Care Uniquely Inefficient?2004Health Insurance Coverage And Mortality Among The Near-Elderly

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2015Lack of private health insurance is associated with higher mortality from cancer and other chronic diseases, poor diet quality, and inflammatory biomarkers in the United States 2021Andersen Model

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