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Dying for Coverage: Charting the Insurance Gap

• May 06, 2008 • 4:18 PM

A recent study shows that life spans are decreasing for some regions in America where reduced access to Medicaid is common.

Most people in the United States have grown accustomed to the idea that each generation will live longer than the previous one. Indeed, a new study shows that the average life span for American men gained 11 years between 1960 and 2000; over the same period, the average life span for women grew by 7.5 years.

But this isn’t true for everyone.

Since 1983, life expectancy for 4 percent of the male population and 19 percent of the female population has either stagnated or worsened, according to the same groundbreaking study by the Harvard School of Public Health and the University of Washington.

Researchers used county data (the smallest measurable unit for mortality data available) in the study, titled “The Reversal of Fortunes,” and were the first to analyze the data over a long period of time — and the first to show a decline in life expectancy among the U.S. population.

“There has always been a view in U.S. health policy that inequalities are more tolerable as long as everyone’s health is improving,” said Majid Ezzati, lead author. “There is now evidence that there are large parts of the population in the United States whose health has been getting worse for two decades.”

The counties with the worst downward swings in life expectancy are in the Deep South, in Appalachia, along the Mississippi River, in the southern portions of the Midwest and in Texas. Researchers found worsening mortality to be largely linked to diabetes, cancers and chronic obstructive pulmonary disease. An increase in HIV/AIDS and homicides played a role for men but not for women.

Other studies and surveys correlate to many of the Harvard/UW findings. One study by The Urban Institute estimated that at least 22,000 adults between the ages of 25 and 64 died in 2006 because they did not have health insurance.

Families USA, a leading health care consumer group, released a survey in April that extrapolated data using methodologies developed by the Institute of Medicine and The Urban Institute to estimate how many people of working age died each week in 2006 in each state because of a lack of health insurance.

Data show that one or two people die each week in a majority of states. Perhaps more interesting is the correlation between states with a higher level of insured residents and states that have instituted some form of health insurance reform.

Hawaii, the first state to set minimum health care benefits for workers, requires all employers to provide health insurance to employees working at least 20 hours a week. A smorgasbord of other options for groups and individuals, as well as managed care, brings a good number of Hawaiians under the health care umbrella. Still, the Families USA study showed that in 2006 some 10.4 percent still were not insured and one working-age Hawaiian dies each week for the lack of insurance.

That is a far cry from Texas, however, where nearly 28 percent of working-age people are uninsured and an estimated 49 die each week because of it, or even Alabama, where 20 percent are uninsured and an estimated seven die each week.

The survey shows “uninsurance is the third-leading cause of death for the near-elderly, following heart disease and cancer,” said Kathleen Stoll, executive deputy director of the organization.

The states showing up in the Families USA survey with the highest death rates fall in the same general regions identified in the Harvard/UW study.

Stoll suggested one reason for that: “There are common factors among states like West Virginia, Mississippi, Alabama and Texas — low levels of eligibility for federal programs.”

She noted that the ways states set rates for Medicaid are a key factor in health care for the working poor.

States can either choose to use the federal poverty level to determine Medicaid eligibility — $20,614 for a family of four — or base their eligibility requirements on a percentage of it; the result is that eligibility varies widely across the country.

Income eligibility for working parents ranges from 28 percent of the poverty level in Texas to 275 percent in Minnesota; for nonworking parents, Texas allows 13 percent of the federal level, and Minnesota again leads the pack with 275 percent.

The trend is toward higher allowances for Medicaid eligibility, with many states beginning to opt for coverage for people earning from 150 to 200 percent of the federal level.

Massachusetts, the first state to require that its residents hold health insurance or pay a penalty, now sets its income eligibility for health insurance coverage at 150 percent of the poverty level for full coverage and subsidizes people earning up to 300 percent of the level.

The Commonwealth Connector, Massachusetts’ independent health authority, enrolled about 350,000 people in health insurance in its first 18 months of operation, about half the estimated uninsured in the state, according to Jon Kingsdale, executive director.

“We reformed the individual nongroup market this summer, and we were able to get prices down by almost 50 percent and double the benefits,” Kingsdale said. He estimates about two-thirds of the remaining 300,000 people uninsured in the state earn less than 300 percent of the federal poverty level.

He offered an example of the good he’s seen as a result. “One of our first enrollees had a chronic sore throat for two years. She’d go to emergency rooms and walk-in clinics, and they’d pass her off with throat lozenges,” he said. “She got enrolled, got care and found out she had throat cancer. She stopped smoking, went through chemotherapy and is doing well today. Without care, she probably wouldn’t be here.”

The high percentage of women identified in the Harvard/UW study correlates in some ways with findings touted in the Families USA survey, which singled out the likelihood of uninsured women being diagnosed with advanced stages of breast cancer.
“There’s no question that these people seek treatment later, and they may not get as good a treatment. If you’re not getting a checkup, you’re not going to get anything diagnosed early,” Stoll said.

Citing a federal program that encourages states to take advantage of a Medicaid program that allows testing for breast cancer, she was quick to add, “The real need is for health care reform where we provide people a reasonable health insurance and not go at it one disease at a time.”

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Joan Melcher
Joan Melcher is a freelance writer and editor living in Missoula, Montana. Her work ranges from travel magazine articles to stories on breaking research.

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