Effect Measure

The uninsured and surviving an accident

Swine flu is a special danger to the young, but the biggest danger to the young is not an infectious disease but unintentional accidents. No matter what your age accident is among the top ten causes of death, but for those between the ages of 1 and 44 it is number one. Prevention oriented accident specialists are fond of saying that “accidents are no accidents,” by which they mean that many accidental deaths are in some sense avoidable, not freakish twists of fortune. So wear your seat belts and don’t go golfing in lightning storms. And while you’re at it, have health insurance, since there is now new evidence that not having it makes it more likely you’ll die if you do have an “accident.”

The finding, in a (free access) paper in the Archives of Surgery by Heather Rosen and her colleagues at Harvard Medical School (hat tip Daniel Cressey, Nature’s blog The Great Beyond), is the latest evidence that being uninsured is bad for your health in all sorts of ways: you are less likely to be screened for colorectal cancer, less likely to be admitted to a specialty hospital for heart attack and heart failure and coronary by-pass, have larger breast tumors, more severe disease and lower rates of surgical treatment, more likely to be organ donors (a reflection of sudden and traumatic death) and get fewer services once in the hospital. Insurance status is an independent predictor of death from trauma in a recent study, but that work wasn’t able to account for the presence of other diseases (comorbidities) that might be more common among the uninsured trauma victim and thus skew the mortality results (these previous findings are cited as references 5 through 12 in the Rosen paper and more extensively described there). The new paper was designed to address the problem that these comorbidities explained why being uninsured made it more likely you would die in a hospital after an accident, even though there is a legal requirement on hospitals meant to prevent your payer status from affecting your emergency care. The Emergency Medical Treatment and Active Labor Act of 1986 makes it illegal to transfer a patient from one hospital to another or even refuse treatment when the patient is medically unstable. Legal or not, there is evidence that your insurance status does matter, and the Rosen et al. study set out to explore what factors were involved. Here’s what they did:

Data were provided by the National Trauma Data Bank (NTDB) (version 7.0), which contains data from 2.7 million admitted patients from more than 900 US trauma centers (from January 1, 2002, through December 31, 2006). As of 2002, there were 1154 trauma centers in the United States. Trauma center participation in the NTDB is voluntary, and thus these data are a convenience sample. The NTDB contains information on patient demographics, preexisting comorbidities, emergency department care, complications, injury severity, patient outcomes, hospital charges, and hospital information.

We included data on adult patients (aged 18 years) who had been injured via blunt or penetrating trauma (we excluded patients with burns). Patients were divided into the following categories of insurance coverage: uninsured (includes self-pay), a managed care organization, commercial indemnity insurance (including automobile insurance, Blue Cross/Blue Shield, no-fault insurance, worker’s compensation, or another commercial indemnity plan), Medicare, and Medicaid, for a total of 5 categories. (Rosen et al., “The Accidental Cost of Being Uninsured,” Arch Surg. 2009;144(11):1006-1011)

The data in the trauma registry enabled the research team (which included Atul Gawande, whose books and articles on medicine and surgery in The New Yorker have brought him independent fame) to account for differences in injury type and severity as well as age, sex and race. The results corroborated what has been found previously: being uninsured puts you at increased risk of dying in the hospital after an injury. The increased risk is substantial (90% increase after accounting for the other factors) and is not explained by comorbidities (age, race and severity of injury all played a part but also didn’t account for the difference; the 90% increase is after taking those factors and comorbidities into account). In fact the difference was greatest in the youngest age group (18 to 30 years) where other medical conditions would be least expected.

Still, it’s not clear what the mechanism for the pervasive risk of being uninsured. The authors mention some possibilities (differences in care once in the hospital, delay in treatment once in the hospital, communication difficulties), but one not mentioned seems to us worth considering (confession: it was Mrs. R. who suggested it). The uninsured may be more likely to live in poor rural areas that are a greater distance from major trauma centers. Distance to hospital apparently was not one of the variables available in the registry, so this a form of “delay of treatment” that remains unaccounted for. The remarkable record of battlefield trauma care tells us that prompt treatment makes a huge difference in outcome (although the disgraceful US record in veteran aftercare is another matter).

The mechanism is important. While we are proponents of a wholesale revamping of American medical care to eliminate effects of income on access to decent and necessary medical care, if the factor is distance to a trauma center it won’t be fixed by extending insurance to more of the population. It would be nice if that is all that is involved and maybe it is. But we’re not there yet.


  1. #1 solanum
    November 20, 2009

    It doesn’t seem that they had data for time of admission after accident or admission method (via ambulance or not). It could also be a factor that uninsured people waited longer to seek medical care or did not call for an ambulance.

  2. #2 Susan Och
    November 20, 2009

    I’m thinking that the level of life support en route to the hospital could be a factor. We all assume that ambulance personnel are highly trained, but there is a wide range of capabilities, even from one town to the next.

  3. #3 Annie
    November 20, 2009

    I think Mrs. R hit the nail on the head. And Susan Och is right also. In criminal justice this has been examined as the Ambulance-Homicide Theory (see: http://www.nytimes.com/2002/12/15/magazine/15AMBU.html?ex=1041043040&ei=1&en=29525eff037b37ed). What effect does access to emergency medical services effect the homicide offending (versus aggravated assualt)in a community?

  4. #4 revere
    November 20, 2009

    Annie: Extremely interesting. Thanks. Link sent to an intentional injury epidemiologist.

  5. #5 DirkKS
    November 20, 2009

    Insurance status likely does affect distance to a hospital, though. It takes money to build a hospital — even with the best of intentions, if the majority of your potential patients won’t pay you because they have no insurance, it’s going to be harder to get a hospital built, or an existing one expanded.

  6. #6 Tasha Chapman
    November 20, 2009

    So, you know that classic anecdote where the patient, before going in for major surgery, writes notes on his body for the doctor, such as “Not this leg”? After reading this I have the strong desire to tattoo “I am insured” on my chest with my health record number…

  7. #7 KeithB
    November 20, 2009

    I am not sure if this is a factor or not, but I just heard on the radio ysterday that they are going to reopen King Harbor hospital as a 125 bed facility.

    They mentioned that this will provide a hospital to 600,000 people who have no access now. It could very well be that like Willie Sutton robbing banks because that is where the money is, hospitals are built where the insured are.

  8. #8 M. Randolph Kruger
    November 22, 2009

    Okay, so the distance to the “healthcare facility” might not have one thing to do with it… How about being run by idiots?

    “L.A.’s Public Health Crisis

    Martin Luther King Jr.-Harbor Hospital is set to close down soon after failing a federal inspection. The action comes after a new round of questions about care, including one in which a woman writhed on the floor of the emergency room lobby for 45 minutes before dying of a perforated bowel. No one stepped in to help her. The Willowbrook hospital, once known as King/Drew, has been plagued by allegations of poor treatment almost since its inception 35 years ago. ”

    That inspection was done by the Bush Administration Revere… I guess that a Democrat would have just have had them up on a gurney to die…Thats healthcare.

    The local accounts from staff and witnesses were that the woman was stepped over, rather than stepped in for help.

    So there is that UHC again. King hospital was closed and it was mostly for costs against reward. If this “plan” goes in it will create a two tiered system. Those that have UHC and then those that have it and co-insurance or another private care insurance. These guys will never see the light of day unless they are young, can be productive and can pay taxes. Thats the death committee concept. If you are a drain on the system then there will be the poster child cases… Just like it was here in Tennessee and the truth of the matter was that they were getting the least care of all… And it was indeed free to them. You just couldnt get anyone to approve anything. Management by committee.

    Ah lets do Universal Health Care and distract attention from the economy. It increases the amount of money that the states have to contribute to this spend-a-thon by not less than 25% on top of what they already contribute if I read it right.

    None of them have it. 33 states are now in budget crisis and California is the first one that I think that will have a bond default. Cant raise taxes in a recession. Cant lay payrolled government employees off in the great socialist state. Whats next? Closing the schools?

    But then there is the bigger potato and that is New York….. Effectively taxing the rich at 65% of income. Yeah, so we tank the local economy too with higher taxes with the idea being that it will generate revenue. BS… Easier to move out of the state. NY will be out of money by the end of December for sure.


    As for the healthcare bill…2000 pages of crap, and I am still reading it. Unbelievable whats in this thing. But its healthcare at all costs, then state defaults, then federal default. Its all good. You cant eat, and you wont have a job, but man you gonna have healthcare baby that someone else has to pay for.


  9. #9 revere
    November 22, 2009

    Randy: No, distance probably does have something to do with it. As for the rest, it’s the tax cut nutters that have ruined public health. Thanks. You get what yo pay for.

  10. #10 Paula
    November 22, 2009

    Kruger, I wish you hadn’t brought this up–at least, on an evening when I’ve some free time. Oh well. You do realize that many of your arguments (#8) speak directly for the need for a single-payer/Medicare-for-All system? I too worry about the compromise healthcare “reform” bills (the stuff that seems to be going through); it would seem indeed that we will simply have a different form of 2-tiered healthcare system, and there still be persons left uncovered. People wanted a reform to provide everyone with quality care; it devolved into “reform” (remember “Welfare reform”?) to save the bleeding, war- and $-meltdown-squeezed US budget. And this should have been obvious from the moment (Feb. or in the choice of budget advisors) when we heard that Medicare (and, then, Medicaid) “trimming” would pay for 1/3 of such “reform”—and certainly as it become clear that the insurance industry sure wouldn’t be asked to (let alone be extracted from the system). Right around that time, I read the Dartmouth Health Atlas and realized that it could not show (though perhaps some of its background studies can?–serious question, if anyone can point out some that do) what some politicos were claiming it could–specifically, show that “less intensivity” of treatment (in terms of tests, specialist visits, etc.) could give as good results as could more intensive treatment—though at least one study it cited (2003 Fisher et al., cited too by Gawande, 6/1 New Yorker) showed promise of such results with some illnesses. At the time, and still, it seemed, and seems, risky to base the safety of Medicare cuts and payments bundling on such a still-uncertain assumption (or any unproven assumption) that quality can be retained; basing one’s healthcare budget on such assumptions, with no way to backpedal should results not turn out as expected, seems most reckless. And yet this is what the patched-together plan of the “fiscal conservatives” may lead to, and to a pitting of the old and infirm against the working young. Taking this all a bit farther, it is scary to read Naomi Klein’s little Shock Doctrine book and watch the financial meltdown, bailout, and nonreform healthcare “reform” compromise-with-the-rightwing plans roll out.

  11. #11 Monado
    November 23, 2009

    The solution: everybody gets the same healthcare with the same criteria. When senators can’t skip off to their gold-plated hospital for front-of-the-line service, you will have an adequate healthcare plan for all. Anything that lets the decision-makers avoid the consequences of their own decision invariably means a ramshackle public system.

    Similarly, the salary of a public official should not be an independent figure but a small mutiple of the old-age pension.

  12. #12 10,000li
    November 23, 2009

    “Tax cut nutters have ruined healthcare.”
    “You get what you pay for.”

    The second is an assertion your post indicates is true, and explains why having personal insurance is almost always better than some government-controlled pool.

    The first is why government-funded medical care is a bad idea: It is subject to the whims of tax-cut nutters.

    In a democratic republic the “will of the majority” deterimines what gets funded and what doesn’t. If the majroity is tax-cut nutters who can’t or won’t think for the long term about the consequences of their votes, or who are motivated by some kind of misanthropy, then, unless the progressives are going to declare a dictatorship, government-funded medical care will be struck from the budget.

    This is why I’m against an federally-run, or even state-run plans: There is no guarantee that those who will become dependent on a socialized (not “socialist”) plan will not be cut off again when the pendulum swings to the right. The bills that are close to being must be rejected by any concientious progressive – the bills have been usurped by the conservatives. This push by the Democrats to “hold their nose” and vote the stuff in no matter how bad it is shows their utter disregard for putting right action ahead of politics.

  13. #13 revere
    November 23, 2009

    10K: I’m glad you can afford it. Live well and prosper.

  14. #14 Paula
    November 23, 2009

    Yes, Monado, yes

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