Health Insurance and Mortality in US Adults

Objectives. A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data.Methods. We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death.Results. Among all participants, 3.1% (95% confidence interval [CI] = 2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI = 1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio = 1.40; 95% CI = 1.06, 1.84) than those with insurance.Conclusions. Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.The United States stands alone among industrialized nations in not providing health coverage to all of its citizens. Currently, 46 million Americans lack health coverage.¹ Despite repeated attempts to expand health insurance, uninsurance remains commonplace among US adults.Health insurance facilitates access to health care services and helps protect against the high costs of catastrophic illness. Relative to the uninsured, insured Americans are more likely to obtain recommended screening and care for chronic conditions² and are less likely to suffer undiagnosed chronic conditions³ or to receive substandard medical care.⁴Numerous investigators have found an association between uninsurance and death.^5–14 The Institute of Medicine (IOM) estimated that 18 314 Americans aged between 25 and 64 years die annually because of lack of health insurance, comparable to deaths because of diabetes, stroke, or homicide in 2001 among persons aged 25 to 64 years.⁴ The IOM estimate was largely based on a single study by Franks et al.⁵ However, these data are now more than 20 years old; both medical therapeutics and the demography of the uninsured have changed in the interim.We analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III). NHANES III collected data on a representative sample of Americans, with vital status follow-up through 2000. Our objective was to evaluate the relationship between uninsurance and death.