Uninsured Face Greater Risk of Death From Colon/Breast Cancer

WASHINGTON—Uninsured Americans confront a greater likelihood of poorer health and premature death than those with private medical and hospital coverage, a committee of the National Academy of Sciences’ Institute of Medicine (IOM) has concluded.

As an example, it cited studies showing that uninsured patients with breast or colon cancer have up to a 50% greater chance of dying, compared with such patients who have private insurance. Going uninsured for even 1 year can diminish the state of a person’s general health.

The findings run contrary to common belief. The panel noted that a 1999 survey found that 60% of the US public believed that the uninsured received the health care they needed from physicians and hospitals.

"Because we don’t see many people dying in the streets in this country, we assume that the uninsured manage to get the care they need, but the evidence refutes that assumption," said co-chair Mary Sue Coleman, PhD, president of the Iowa Health System and the University of Iowa. "The fact is that the quality and length of life are distinctly different for insured and uninsured populations."

In its second of six reports examining the consequences for those without health insurance, the panel addressed a diverse group of problems—cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental illness, traumatic injuries, and heart attacks.

In the report, "Care Without Coverage: Too Little, Too Late," the group focused on these illnesses as they relate to the 30 million uninsured, working-age Americans younger than 65. It did not address the consequences for the nation’s nearly 10 million uninsured children.

"It wasn’t difficult for us to conclude that if the uninsured became insured on a continuous basis, their health would improve and they would live longer," said co-chair Arthur L. Kellerman, MD, professor and chair, Department of Emergency Medicine, Emory University School of Medicine.

Indeed, the panel said its findings probably understate the problem nationwide because it could not assess the impact of being uninsured on people who did not seek treatment, and the uninsured are less likely than insured adults to seek medical care. Among its major findings, the committee concluded that being uninsured was associated with the following:

• Less frequent or no cancer screening tests, which resulted in delayed diagnoses and premature mortality for cancer patients.

• Care that does not meet professionally recommended standards for the management of chronic disease. For example, diabetics may fail to receive timely eye and foot examinations to prevent blindness and amputation.

• Lack of access to and maintenance of appropriate medication regimens for persons with hypertension or HIV infection. Fewer diagnostic and treatment services for trauma or heart attacks and an increased risk of death when in the hospital.

"Being uninsured for relatively short periods (1 to 4 years) appears to result in a decrease in general health status," the report said. "When followed over longer periods of time, uninsured adults have been found to be at higher risk of premature deaths than are persons with private coverage." It added that the decline in health among the uninsured is most profound for adults age 55 to 65.

Patients With Cancer

In its section on cancer, the committee found that "uninsured cancer patients generally are in poorer health and are more likely to die prematurely than persons with insurance, largely because of delayed diagnosis. This finding is supported by population-based studies of persons with breast, cervical, colorectal, and prostate cancer, and melanoma."

The report specifically noted that the uninsured were less likely than the insured to get preventive services such as mammograms, clinical breast exams, Pap tests, and colorectal screening.

"Even after adjustments for age, race, education, and regular source of care, uninsured adults are less likely to receive timely screening for breast, cervical, or colorectal cancer," the report said. "Once discovered, their cancer is likely to be at a more advanced stage." As a result, "uninsured cancer patients die sooner, on average, than do persons with insurance."

The panel also noted that health insurance plans are generally less likely to cover preventive and screening measures than diagnostic tests for symptomatic conditions. Even when insurance plans fail to cover preventive care, the insured are more likely than the uninsured to get appropriate services, "partly because they are more likely to have a regular source of care or a primary provider."

Moreover, uninsured adult cancer patients sometimes receive different treatment than the insured. As an example, the committee noted that uninsured breast cancer patients are less likely than insured patients to receive breast-conserving surgery. "It should be noted," the report added, "that disparities in treatment persist among racial and ethnic groups even if all have insurance."

Patients With HIV

Uninsured adults diagnosed with HIV infection face greater delays than insured patients in obtaining appropriate care and are more likely to forgo needed care. "Persons without health insurance have been shown to wait more than 3 months after diagnosis to have their first office visit and to wait an average of 4 months longer than privately insured patients to receive new drug therapies," the report said. "Furthermore, the uninsured with HIV are less likely to be able to maintain a recommended drug regimen over time."

Uninsured HIV-positive adults are less likely to get the drug "cocktails" proven highly effective in recent years in improving the survival of HIV patients. "Having health insurance of any kind has been found to reduce mortality in HIV-infected adults by 71% to 85% over a 6-month period," the committee said.