Summary: Stellar health system modeling and empirical analysis together quantify what many of us suspected all along – the huge uninsured problem in the U.S. increased the COVID death toll by reducing access to care. Fully one quarter of all COVID deaths are due to the absence of universal insurance.
Universal healthcare as pandemic preparedness: The lives and costs that could have been saved during the COVID-19 pandemic, PNAS (Proceedings of the National Academy of Sciences), June 13, 2022, by Alison Galvani et al.
Abstract: The fragmented and inefficient healthcare system in the United States leads to many preventable deaths and unnecessary costs every year. During a pandemic, the lives saved and economic benefits of a single-payer universal healthcare system relative to the status quo would be even greater. For Americans who are uninsured and underinsured, financial barriers to COVID-19 care delayed diagnosis and exacerbated transmission. Concurrently, deaths beyond COVID-19 accrued from the background rate of uninsurance. Universal healthcare would alleviate the mortality caused by the confluence of these factors.
To evaluate the repercussions of incomplete insurance coverage in 2020, we calculated the elevated mortality attributable to the loss of employer-sponsored insurance and to background rates of uninsurance, summing with the increased COVID-19 mortality due to low insurance coverage. Incorporating the demography of the uninsured with age-specific COVID-19 and nonpandemic mortality, we estimated that a single payer universal healthcare system would have saved about 212,000 lives in 2020 alone.
We also calculated that US$105.6 billion of medical expenses associated with COVID-19 hospitalization could have been averted by a single-payer universal healthcare system over the course of the pandemic. These economic benefits are in addition to US$438 billion expected to be saved by single-payer universal healthcare during a nonpandemic year.
Results: Across the entire time frame of the pandemic thus far … 338,594 COVID deaths are attributable to incomplete insurance coverage in the United States.
Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study, The Lancet Regional Health – Americas, May 12, 2022, by Travis Campbell et al.
Summary
Background: … Comparing regions with different rates of health insurance, we assess how much of this excess mortality may be due to the relatively large population without health insurance.
Methods: We use daily COVID surveillance data from the US Centers for Disease Control and Prevention (CDC) stratified by region, age group, gender, and race in regression analysis of cases, hospitalization, and mortality. COVID-19 data have been matched with structural characteristics of the region including average proportion with health insurance.
Findings: Groups with lower health insurance coverage had significantly higher mortality as well as greater case counts and hospitalization. Early in the pandemic, they were also less likely to be tested for COVID-19. Applying our regression estimates, we estimate that had there been full health insurance coverage of the population, there would have been … a 26% [lower] death toll ….
Interpretation: Our study demonstrates that a significant share of COVID-19 mortality in the United States … is due to our reliance on a system of market-driven healthcare.
Comment:
By Jim Kahn, M.D., M.P.H.
This important pair of studies (disclosure: I’m a co-author on one) demonstrate using state-of-the-art scientific methods the shocking extent of excess U.S. COVID mortality due to lack of health insurance. One third of a million unnecessary deaths, and still rising.
We have written in HJM about how poorly the US has fared with COVID compared with Taiwan and other countries. We’ve speculated on the role of poor access to primary care, driven by lack of insurance and thus financial barriers.
Now we have a firm numerical estimate, using empirical analysis of COVID surveillance, plus integration of these and other data into a comprehensive portrayal. Speculation is replaced by quantification of the huge health consequences of our insurance gaps.
The system portrayal also demonstrates that our healthy system wasted more than half a trillion dollars in 2020, between ongoing inefficiency and care for excess COVID cases.
What are the mechanisms? Health care access leads to earlier diagnosis, with better treatment and reduced transmission, as well as stronger prevention such as higher vaccination rates. (Promises of special insurance coverage for COVID fall short when individuals don’t know about it, and when implementation is seriously flawed.) Fewer cases also mean lower hospital burdens that may compromise quality of care.
Can the COVID experience tip the scales toward single payer? Let’s use these sad statistics to achieve great reform. Future pandemic responses should not be hindered by insurance frailties.
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