No one, to our knowledge, has actually come up with an estimate of the number of residents in America, legal or illegal, who are denied life-saving medical care—if indeed there are any. Even accusations of violating EMTALA—the Emergency Medical Treatment and Active Labor Act, which requires screening and stabilization of any patient presenting to an emergency room—are apparently rare.

The 46 million are the “uninsured.” They lack “coverage,” not care.

The Institute of Medicine and the Kaiser Commission on Medicaid and the Uninsured have published widely cited 2002 reports concluding that uninsured people have worse health than insured people. The IOM guesstimates that 18,000 people a year die for lack of insurance—an impressive sound bite that “has no factual basis,” writes Greg Scandlen.

In the actual report, the number 18,000 occurs only once, in Appendix D, with a description of the convoluted method for calculating it—extrapolating from one questionable estimate from one study.

Scandlen observes that neither IOM nor Kaiser did any original research, but simply compiled previous studies. These identify a correlation between lack of insurance and poor health, but cannot determine whether one is caused by the other, or both are caused by some other factor.

In the U.S. 37% of people with below-average income reported that they were in fair or poor health, while only 9% of people with above-average income said the same. A similar disparity is seen in the UK, New Zealand, Canada, and Australia, despite their “universal coverage.”

People in lower income groups are more likely to be uninsured, but only 18 of the 164 separate studies made any effort to control for income. The Medicaid population, being low income and well-insured, could serve as a control group. In 61% of the 31 studies that identify three populations (privately insured, uninsured, and Medicaid), Medicaid recipients appeared to do as badly or worse than the uninsured in receiving medical services or maintaining good health. In many cases, they have worse outcomes than the uninsured. This is consistent with other information suggesting that income is a much better predictor of health than is insurance status (ibid.).

Smoking and education level were other confounding variables that the IOM failed to consider (David Hogberg, American Spectator 9/22/09).

While the increasing number of uninsured is presented as a crisis, the proportion of Americans without health coverage has changed little in the past decade. The increase in number is owing to immigration and population growth, writes Devon Herrick.

In 2006, 15.5% of Americans were uninsured, compared with 16.2% in 1997.

Of the claimed 46 million uninsured, 12.6 million (27%) are immigrants, either legal or illegal. Up to 14 million (30%) are eligible for government insurance, but haven’t bothered to enroll. They can sign up the instant they need medical attention.

The percentage of low-income people (<$25,000/yr) without insurance actually decreased 24% over the past 10 years. The highest rate of increase in uninsured status, 90%, was in families with incomes over $75,000, who presumably could have bought insurance if they considered it worth the price.

Insurance “coverage” is not the same thing as medical care. It is not necessarily the best way to pay for medical care—although it probably is the most expensive. And there is no actual evidence, only inference from uncontrolled observational studies, that increasing the level of insurance coverage improves health outcomes. If expanding coverage means restricting care, the opposite could occur.

Additional information:

• “The Uninsured: Reframing the Issue,” AAPS News, November 2004.
• “The Coverage Trap,” AAPS News, May 2004.
• “Down with ‘Health Plans’!” AAPS News, January 2004.
• “‘Covering’ the Uninsured: the Wrong Goal,” AAPS News, April 2003.
• “‘Giving’ and Taking,” AAPS News, January 1992.