Increased risk of death among uninsured neonates

By Frank H. Morriss Jr
Health Services Research (HSR), August 2013

Abstract

Objective

To estimate the contribution of health insurance status to the risk of death among hospitalized neonates.

Data Sources

Kids’ Inpatient Databases (KID) for 2003, 2006, and 2009.

Study Design

KID 2006 subpopulation of neonatal discharges was analyzed by weighted frequency distribution and multivariable logistic regression analyses for the outcome of death, adjusted for insurance status and other variables. Multivariable linear regression analyses were conducted for the outcomes mean adjusted length of stay and hospital charges. The death analysis was repeated with KID 2003 and 2009.

Principal Findings

Of 4,318,121 estimated discharges in 2006, 5.4 percent were uninsured. There were 17,892 deaths; 9.5 percent were uninsured. The largest risks of death were five clinical conditions with adjusted odds ratios (AOR) of 13.7–3.1. Lack of insurance had an AOR of 2.6 (95 percent CI: 2.4, 2.8), greater than many clinical conditions; AOR estimates in alternate models were 2.1–2.7. Compared with insureds, uninsureds were less likely to have been admitted in transfer, more likely to have died in rural hospitals and to have received fewer resources. Similar death outcome results were observed for 2003 and 2009.

Conclusions

Uninsured neonates had decreased care and increased risk of dying.

From the Discussion:

Effects of Insurance Status

As expected, the predictors with the largest adjusted risks for death during hospitalization of neonatal patients estimated using the KID 2006 database were clinical conditions commonly encountered in neonatal intensive care units, that is, PT/LBW/IUGR, IVH, hypoxia, NEC, and congenital malformation. In this analysis, uninsured status was the next largest adjusted risk for death, for which the AOR, 2.6, was greater than those for sepsis, obstetrical conditions and complications, RDS, multiple birth, and male gender. Lack of insurance was also a significant predictor of death in analyses of both the 2003 and 2009 KID databases. The estimate of the effect of insurance was not changed in models for the outcome of death that excluded the hospital variable, indicating that the disparity is a within-hospital disparity.

Socioeconomic Position, Relative Isolation, and Race

Socioeconomic position, place of residence, race, and health insurance status are interrelated factors, each of which may independently predict the hospital death of a newborn, adjusted for clinical predictors and each other. However, it is difficult to separate the effect of lack of health insurance in the United States from socioeconomic conditions that may predispose to that condition. A significant unadjusted association exists in this analysis between uninsured status and the distribution of median household income indicated by ZIP code toward lower quartiles; a separate association exists between uninsured status and rural residence. Measures of poverty, income inequality, and social deprivation, not including health insurance status, have been associated with adverse neonatal or infant survival risks (Singh and Kogan 2007; Olson et al. 2010).

http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12042/full

Comment:

By Don McCanne, M.D.

Although socioeconomic factors play an important role in neonatal mortality, it is clear that lack of health insurance is an important contributor to these tragic deaths. We have much to do as a society to correct these injustices, but perhaps the easiest first step would be to ensure that everyone is automatically insured, including neonates. The Affordable Care Act will not do that, whereas enacting a single payer national health program would.