Dying for (Media) Coverage

In the series of reports, called “Dying for Coverage,” Families USA purports to show how many people are killed by a lack of health insurance in each state.  For example, they claim 6 people die every day in Florida because they are uninsured.  Seven die every day in Texas, 8 in California, and 25 in New York.

How is Families USA able to tally up all this carnage with such pinpoint precision?  As it turns out, these claims are based on a 15-year cascade of studies – each repeating the errors and misinterpreting or mischaracterizing the findings of the previous one and ultimately relying on data that is 37 years old.

Let’s start at the beginning.  A paper by Peter Franks et al. published in Journal of the American Medical Association in 1993 estimated that there were 1.25 deaths among those without health insurance for every death among those with health insurance. To arrive at that number, the authors compared the cumulative mortality by 1987 of people who were either privately insured or uninsured at the time of a survey taken from 1971 to 1975.

Note:  If the subjects studied were normal, those who were uninsured in the original survey would have remained so for only a short period of time, and over the 19 year interval members of the whole group would have experienced shifts of insurance status (from insured to uninsured and back again) several times.  Being uninsured, after all, is like being unemployed.  Lots of people experience the condition, but usually for short periods of time.  Yet if this is true, it’s hard to draw any meaningful inference from the study about the effects of insurance on mortality.

For the study’s inference to be meaningful, one almost has to assume that the uninsured stayed uninsured for the full 19 years!  But if that were so, the group would in no way be representative of the U.S. population as a whole.

To make matters worse, the authors claim their findings support “universal health insurance to reduce both financial barriers to care and the risk of premature mortality.”  Yet the study itself provided no information about the effects of government coverage on mortality because it excluded “adults with Medicaid, Veterans Administration insurance, or Medicare.”

A 1994 paper by Sorlie et al. in the Archives of Internal Medicine did provide information on the effects of government coverage on mortality. It reported that people on Medicaid and Medicare had higher mortality than either the uninsured or those with private insurance.

Continuing the saga, the Institute of Medicine (IOM) uncritically used the Franks result to claim that 18,000 deaths a year in the U.S. are attributable to a lack of health insurance.  (See the 2002 report Care Without Coverage: Too Little, Too Late.)  The justification for this widely-publicized estimate appears in Appendix D, where the IOM adopts the Franks’ 1.25 ratio without explanation or discussion.

In January 2008, the Urban Institute published a report by Stan Dorn updating the 2002 IOM mortality estimates by combining IOM methodology with the latest Census Bureau estimates of the uninsured.

Families USA applied the Urban Institute updates and the IOM method to even more imprecisely estimated state data to produce its Dying for Coverage series.  Page 2 of the Urban Institute report explains the methodology used to create the IOM estimates, the Urban Institute estimates, and the Families USA estimates.  Consider 25 to 34 year olds.  Deaths are allocated among the insured and uninsured for this group in the following way:

  1. Take the percent of insured (79%) and the percent uninsured (21%) in this age group from the Current Population Survey.
  2. Let X be the rate at which the insured in this age group die.
  3. Assume that the rate of uninsured death is 1.25 times X (from Franks).
  4. Add the death rate of the insured and the death rate of the uninsured together to get total deaths. Using U.S. vital statistics data this yields 40,548 = (0.79*X) + (0.21*(1.25*X)).
  5. Do simple algebra to get 40,548 = 1.05*X.
  6. Divide by 1.05 to get the number of deaths assumed to be attributable to the insured population, 38,617.
  7. Claim that the 1,931 difference between total deaths and the deaths attributable to the insured population are “excess deaths” due to a lack of health insurance.

Note that in the seven steps listed above, there is no point at which anyone from Families USA actually examines a medical record.  There is no interview with any doctor, any patient or any family of a deceased patient.  There is only algebraic mumbo jumbo in support of an unsupportable claim.

Note also that in the age group 25 to 34, more than half of all deaths are due to accidents, suicides and assaults.  How, you may wonder, does insurance status affect these deaths?  In their publication, Families USA says the uninsured have a higher mortality rate because they (a) are less likely to have a usual source of care outside of the emergency room, (b) often go without screening and preventive care and (c) often delay or forgo needed care.  However, they do not explain how any of these factors cause death by accident, suicide or assault.

Comments (13)

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  1. Bethany says:

    Thanks so much for the media alert. AS I read the second sentence of your health alert article, my stomach lurched. I do not have health insurance. I’ve worked out 5 to 6 days a week for my entire adult life. Even when I went into labor for my last child’s birth, I was on the Stairmaster. I am 57 years old and have been to the doctor a few times in my life, other than pre-natally speaking. I have been raised to eat primarily foods that come directly out of the ground and the sea; with small portions of meat, chicken and pork thrown in. Anything in a box should be rationed as a special treat and eaten as infrequently as practical; unless it’s something like oatmeal or another equally awful, but HEALTHY alternative to fresh fruits and veggies.

    But, the funny thing is that my stomach lurched as if this doomsday report was going to kill ME, instantly. Guess what, we all will depart from this life one day, reporting done or not. But, what I find to be critical is to live every day well and part of living it well is to treat your body to a daily regiment of proper diet, exercise and rest, so you’ll feel pretty good as you travel through life.

    When I was little, my family did not have any insurance. We visited a doctor if we were really sick. Once I had a staph infection in my finger and once I had an earache and once I had a sore throat with accompanying high fever. That and getting immunizations was the only time I or my 6 siblings ever saw a doctor. My mother was our family health care professional. She taped really big cuts that should have been stitched (the health professionals now do this, too). She peroxided us to pieces. She opened up all the windows (even if it was 22 degrees outside) after someone caught the flu, she never allowed us to stay home from school unless we had a bonafide fever of 102 degrees, she made us eat fruits & veggies ad nauseum, and she made us work. Vacuuming was a daily or twice-daily ritual; toilets too were done very often. We had a dishwasher, but her thought was that if we used it then it might break and then what???? We wouldn’t have a dishwasher……….so we hand washed ever pot, pan, dish, fork, spoon etc…….Dusting and polishing and base board washing was part of the regiment, along with window washing every month. My fondest memories include the silver polishing of three complete sets of silver, plus all those horrid tea sets….. Basically, our house was NEVER clean enough for her ole white glove……………..BUT HERE’S THE KICKER……. WE WERE ALMOST NEVER SICK!!!

    Today she is 85, she works still, exercises, takes vitamins, drives her car and still drives us all nuts with her cleaning frenzies, but we are all still pretty darn healthy.

    So, for a good life without insurance, the answer is to have a health-care Mom, like mine. HAPPY MOTHERS DAY TO ALL!!!!

  2. Dave Racer says:


    I had a health agent in New Jersey yell at me for making light of this. He walked away in exasperation actually stating that “being uninsured is the third highest cause of death in Pennsylvania.” Now that I think of it, I think he was joking. At least I hope so.

    My gosh.

    25,000 Brits die of cancer because of a lack of oncologists (according to your earlier study). That’s the same as 125,000 in the U.S., and that does not happen.

  3. Dan Smith says:

    The inclusion of the Institute of Medicine in this fiasco does not surprise me. It’s uncritical endorsement of an old and flawed study out of Harvard was responsible for a lie that has raced around the world several times while the truth hunted for its shoes under the bed. I am referring to the allegation that medical errors kill 100,000 Americans every year. Every politician seeking to pander to the undercurent of paranoia in American life has made reference to those figures, which are a complete exaggeration of the real incidence as measured by states like Minnesota, which mandates hospitals to report adverse events.

  4. Bill Waters says:

    And how many of these uninsured deaths were in the 10 million who were eligible for Medicaid, in the 12 million illegal aliens, and in the 10-12 million with incomes above $50,000?

    If a program were implemented to cover these, it would look like Medicaid, which has the highest mortality of all.

  5. Steve Wemple says:

    Excellent job of De-bunking another accepted myth

  6. David Wilson says:

    John, great report, great blog. Thank you.

  7. Ralph F. Weber says:

    I have the solution:

    We need to identify the top 20% of income earners in the US and then allow the other 80% of Americans not to work, as long as they consume goods produced by the 20%. Then we can heavily tax the 20% who work and re-distribute this wealth to the 80% so that they can afford to buy goods.

  8. Ed Harper says:

    How does Families USA get away with this kind of fraud against the American public?

  9. Peter Farrell says:

    Totally disgusting. But we might need to get used to this type of misinformation as the Democrats get into full swing later in the campaign.

  10. […] in the US are now said to range from 98,000 to 195,000 every year. The lower number comes from a discredited Institute of Medicine estimate. The higher number comes from HealthGrades, a hardly disinterested party in the business of selling […]

  11. […] was Families USA able to tally up all that carnage with such pinpoint precision? As Linda Gorman explains, these claims are based on a 15-year cascade of studies — each repeating the errors and […]

  12. […] was Families USA able to tally up all that carnage with such pinpoint precision? As one of us previously explained, these claims are based on a 15-year cascade of studies — each repeating the errors and […]

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