By Debra Wood, RN, contributor
Nov. 20, 2009 - The lack of health insurance is associated with nearly 45,000 deaths annually in the United States, the only industrialized nation without universal health care, according to a new study from researchers at Harvard University in Boston. Other studies have found increased mortality rates among the uninsured, as well, even in trauma situations.
NYU Dean Terry Fulmer, RN, PhD, FAAN, points out that nurses have an opportunity to make a difference in uninsured people's lives.
"We need to take it seriously that people without health insurance have a higher rate of mortality, and all of us need to think about how we will reach out to those who are uncovered," said Terry Fulmer, RN, PhD, FAAN, dean of the New York University College of Nursing. "Every time a nurse is in contact with a person without insurance, it's an opportunity."
Fulmer called the study credible and suggested that nurses can intervene to help the uninsured find coverage or services. New York University nursing faculty provide care to the uninsured in a clinic, and the college of nursing sends a mobile health van to a low-income school to serve teens and reach out into their family networks.
"The number of deaths as a result of lack of insurance are startling," added Linda Tarr-Whelan, RN, BSN, author of the book Women Lead the Way: Your Guide to Stepping into Leadership-and Changing the World. "Nurses have a lot to say and have to speak out to make a difference."
While staggering, the numbers may not surprise nurses and physicians who provide emergency care to uninsured patients or practice in free clinics serving low-income, uninsured people. The uninsured often ignore symptoms, skip recommended screenings and delay seeking medical attention for chronic conditions, because they lack access to the health care system.
The U.S. Census Bureau reports 46.3 million Americans were uninsured in 2008, the most recent available data. That's up from 45.7 million in 2007 and 38 million in 2000.
The Harvard research team analyzed data for adults younger than 65 years from the third National Health and Nutrition Examination Survey (NHNES), a representative sample of Americans conducted between 1988 and 1994, to evaluate the relationship between health insurance and mortality. The researchers controlled for education, income, smoking, drinking and obesity. They found that uninsured, working-age Americans have a 40 percent higher risk of death than their privately insured counterparts.
"Historically, every other developed nation has achieved universal health care through some form of nonprofit national health insurance. Our failure to do so means that all Americans pay higher health care costs, and 45,000 pay with their lives," said Steffie Woolhandler, study co-author, professor of medicine at Harvard Medical School, and a primary care physician at Cambridge Health Alliance, in a written statement.
Numerous other studies have shown a link between being uninsured in the United States and dying, but this one pegged the rate higher than the Institute of Medicine's 1993 study, which found a 25 percent higher risk and linked being uninsured with about 18,000 deaths.
"The Institute of Medicine, using older studies, estimated that one American dies every 30 minutes from lack of health insurance," remarked David Himmelstein, study co-author, associate professor of medicine at Harvard Medical School, and a primary care physician at Cambridge Health Alliance, in a written statement. "Even this grim figure is an underestimate--now one dies every 12 minutes."
The researchers also found higher death rates for males, current or former smokers, and those who were determined to be in fair or poor health, by their own evaluation or that of a physician. The uninsured are more likely to go without care and may have undiagnosed conditions.
"We doctors have many new ways to prevent deaths from hypertension, diabetes and heart disease--but only if patients can get into our offices and afford their medications," said lead author Andrew Wilper, MD, PhD, now a faculty member in the general internal medicine program at the University of Washington School of Medicine, in a written statement. Wiper was at Harvard during the time the research was conducted.
In a new study published in the November 2009 issue of Archives of Surgery, Heather Rosen, MD, MPH, a former research fellow at Children's Hospital Boston and Harvard Medical School, and colleagues reported that insurance coverage also affects trauma patients' mortality rate. They analyzed data from the National Trauma Data Bank from 2002 to 2006. About 690,000 patients were included in this study.
"Uninsured patients in the United States have a higher risk of dying after trauma even though there is universal access to emergency care," said Rosen, now a surgical resident at the Keck School of Medicine of the University of Southern California in Los Angeles. "We found that the uninsured population overall has an 80 percent higher risk of death than patients with commercial insurance."
When the team looked at a subgroup of young patients, those between 18 and 30 years of age, their risk of death if uninsured was 89 percent higher than their counterparts with commercial insurance.
In a different study, Rosen and colleagues determined that uninsured children were more than three times more likely to die from their trauma-related injuries than children who were commercially insured, after adjustment for other factors such as age, gender, race, injury severity and injury type.
The authors speculate that uninsured patients may experience treatment delays; receive different care, including fewer diagnostic tests; or possess a lower rate of health literacy.
"Our hope is that when universal health care coverage becomes a reality, this disparity will attenuate," Rosen said.
Nurses can help make that happen, because they are trusted professionals and bring a perspective that comes from patients, Tarr-Whelan said. She encourages nurses to contact their members of Congress, to become involved in their professional organizations, and to join any local task forces addressing health care access issues.
"Nurses are essential to any realistic reform that will last," Tarr-Whelan said. "Nurses could make a big difference in the health care debate in Washington."
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