Tuesday, October 21, 2008

Yes, another post about needing universal health insurance

I know I've been posting on this topic a lot lately, but in my feeble head universal health care = more patients in the system = more buildings and spaces needed to serve them = more work for me.  I find this article interesting and question-provoking, not the least of which is: WHY?  After reading Malcolm Gladwell's Blink, I have to wonder if something very, very subtle is a work here.  Does minority = not worth givng the very best of care?  Or does non-insured = not worth saving?

Minority, uninsured trauma patients more likely to die in ED, study suggests

Black, Hispanic, and uninsured trauma patients are more likely to die in U.S. EDs compared with white patients, but insurance status has the stronger association with mortality after trauma, according to a study published in the October issue of the Archives of Surgery. To determine the effect of race and insurance status on trauma mortality, researchers from Johns Hopkins University School of Medicine and colleagues analyzed outcomes for 376,897 patients in the National Trauma Data Bank. Treated between 2001 and 2005, the study sample included 72,249 black patients, 41,770 Hispanic patients, and 262,878 white patients; patients ranged in age from 18 to 64 and had moderate to severe injuries. Overall, 47% of patients had insurance, but blacks and Hispanics had higher uninsured rates than whites. The researchers found an adjusted mortality risk after trauma that was 17% higher for black patients and 47% higher for Hispanic patients than for white patients. Meanwhile, the researchers found that insured patients had a lower crude mortality rate compared with uninsured patients, at 4.4% and 8.6% respectively. The absence of health insurance increased a patient’s adjusted mortality risk by nearly 50%. According to the lead author, the dramatic differences in mortality risk between insured and uninsured patients were unexpected, given that access to trauma care in the United States does not hinge on insurance status. However, among insured patients, both Hispanics and blacks had “significantly” higher mortality risks compared with white patients, suggesting that “racial disparities in trauma mortality cannot be completely explained by insurance status alone.” As such, the researchers recommend further research into the “underlying reasons for these differences, which will enable to development of interventions to close the gap between patients of different races and payer statuses” (Haider et al., Archives of Surgery, October 2008 [subscription required]; Phend, MedPage Today, 10/20; Reinberg, HealthDay, 10/20).

Either way, this study at least suggests that having insurance might save your ass in the ED.  Let's also remember from some earlier posts here (and studies elsewhere) that the ED is the main place where uninsured people go for all healthcare because they can't be turned away.  It may be more likely, I dare posit, that the uninsured have a higher mortality rate in the ED because they wait too long for treatment and come to the ED when it's too late.  Which is a condition that universal health care would very likely alleviate.

I know my posts have been shoddy lately, and I intend to rectify that as soon as possible.  It's hard to talk about architecture when I've actually spent 3.5 days this month cleaning my desk and not working on a whole lot of real architecture.


faded said...

Having spent an evening in the ED after a bad car accident, I would ask the authors of the study if they took into account the overall health of each ethnic group. Blacks overall tend to be in poorer health than Whites and Hispanics. There are cultural reasons why blacks tend to be in poorer health. They are generally very afraid to go to the doctor. I do not know why this is, but it has been documented and I have seen it among my black friends.

Also many of the Hispanics are probably illegals. They will tend to be in poorer health because of their residency status. Hispanics who have legal residency have access to insurance at rates equivalent to Whites.

Both groups tend to be sicker and the extra level of compromised health will lead to a higher death rate.

The question of death rates by insurance is a good one, I wonder about the study you quoted because they did not try to normalize the data to take out differences in the back ground health of each group. I have to ask this question. What is the agenda that the authors of the study are trying to advance?

I have two rather radical suggestions for solving the health care problem.

The first is to abolish all health insurance, private and government. This is based on the idea that insurance tends to remove the efficiency from the health care system. As an example, the cost of insured medical procedures has been going up around 9% to 11% a year for the last few years, after you adjust for inflation. It turns out that cost uninsured medical procedures has been declining. The real cost of elective plastic surgery has been declining at the rate of 2% a year. The plastic surgeons know that they must be efficient and have good results if they are to stay in business. In 1980 a breast enhancement cost $20,000. Recently I saw an ad in the local newspaper for a breast enhancement for $4,000. The administrative burden of insurance adds, depending on who you ask, between 11% and 18% to the cost of health care today. If we abolish insurance we can bring efficiency to the system. We would have to find a way to do this that would not cause major disruptions during the conversion period. There is something wrong with a medical system where on of the cheapest medical procedures you can get is a boob job.

The second approach is to use a system like the one in Germany. It is not government run socialized medicine. Germany has a pool that everyone pays into. The pool is administered by private insurers who pay the bills. If you want an insurance based system this is appealing because it is run by for profit insurers who will have a motivation to be efficient. Not by the government.

The Canadian socialized system does not work very well. The socialized system in Canada only covers about half of a person's medical costs. It turns out that a private pay system is growing up along side the socialized system to compensate for its' short comings. If you watched Ice Road truckers this year, you saw Alex Deborkowski, one the truckers, get medivaced off the ice due to a heart condition. He paid for the plane ride personally. The health care system did not. The ride may have cost him $12,000 Canadian. This same thing happened in first year of the show with a different truck driver.

Mile High Pixie said...

Faded: you make a good point about race and medical history in the US. It would be interesting to see what mortality rates are like if the study controlled for history or citizenship status. Indeed, having insurance doesn't necessarily mean people will use it--plenty of folks in the US and the UK just won't go to the doctor when they are injured or ill.

Also true is that the medical systems to use as examples around us aren't necessarily perfect or even good examples. I recall Alex this year and that younger man last year having to pay for the flight to the hospital and thinking that was a little odd. My healthcare pays for some but not all of an ambulance ride, and I'm still left with a bill for several hundred dollars. I've also heard that in the UK, many folks will pay extra for some private insurance to receive extra/better care. I've met folks who have had medical care in France, and their report was that the lines were long to wait at the clinic but the care was thorough and excellent.

At the same time, my sister spent a fair amount of her adult life without health insurance, and it made any and every illness a costly one. for the most part, her health plan was "don't get sick". I have coworkers who used to receive healthcare through the government when they were in the armed forces, and they said that healthcare was AWFUL. So perhaps the solution isn't purely government or private-based insurance, but something in between.

Mile High Pixie said...

Oh, and my belated but heartfelt prayers and thanks go out for your recovery, Faded. It's great to have you back, commenting and reflecting.