Fact and Fiction: Debunking Myths in the US Healthcare System

Umut Sarpel, MD; Bruce C. Vladeck, PhD; Celia M. Divino, MD; Paul E. Klotman, MD


Annals of Surgery. 2008;247(4):563-569. 

In This Article

Myth 3: The Uninsured Have Equal Access to Medical Care Through the Emergency Room

While admitting that the system is flawed, many people feel a sense of complacency, believing that the uninsured still have access to healthcare through emergency departments. Although inconvenient to obtain, the same quality of care is ostensibly available to the uninsured and the insured. Although this is true in theory, it is not realized in practice.

Multiple studies have shown that the uninsured receive less healthcare and have worse outcomes than the insured.[27,28] The Institute of Medicine reports that working-age Americans without health insurance are more likely to receive too little medical care and receive it too late; be sicker and die sooner; and receive poorer care when they are in the hospital, even for acute situations like a motor vehicle crash.[27] After adjusting for age, gender, smoking, and education, lack of insurance alone increases risk of death by 25%.[29]

This increase in mortality is independent of income level.[30,31] In other words, it is not being poor per se that leads to the adverse effects of being uninsured. The lack of insurance interrupts the patient-physician link, which is necessary to pursue good health. For example, diabetes cannot be cured but its effects on the body can be attenuated with strict glucose control and regular surveillance. In a study comparing insured and uninsured patients with diabetes, those lacking insurance had statistically lower rates of the recommended eye and foot examinations, vaccines, glycosylated hemoglobin screening, and checks of cholesterol level (Figure 3). [32] In patients with kidney failure, the uninsured start dialysis at a later stage of disease. Uninsured patients with HIV are less likely to receive effective drug therapy. The uninsured are screened less often for hypertension and are less likely to take blood pressure medication prescribed to them.[27]

Diabetes management among insured and uninsured adults. Reproduced with permission from The Institute of Medicine.

The uninsured suffer poorer outcomes across surgical disciplines as well. Although the insured meet goals of 90% for cervical cancer screening, 70% for breast cancer screening, and 50% for colorectal cancer screening, a recent study shows that the uninsured fall well short of these goals, reporting 77%, 52%, and 29%, respectively.[31] As a result, uninsured people (or those with Medicaid) have more advanced cancers at the time of diagnosis and/or lower survival rates for breast cancer, colon cancer, cervical cancer, prostate cancer, and melanoma.[27,33,34] Patients without health insurance present more often with perforated appendicitis.[35] Individuals with ulcerative colitis and private insurance are more likely to undergo colectomy than their uninsured counterparts.[36] In a study of over 5000 patients with abdominal aortic aneurysms, those without medical insurance were significantly more likely than individuals with private insurance to suffer rupture.[37] There are a remarkable number of studies that draw a strong correlation between lack of insurance and poorer health.

Finally, the care administered to the uninsured in the emergency department setting is generally more costly to the national budget. When there is no preexisting patient-doctor relationship, the physician finds it more difficult to gauge a patient's symptoms and to rely on follow-up. For example, a patient in the emergency room with mild pain on urination will undoubtedly be prescribed an antibiotic. This same patient, if seen in a generalist's office, might be asked to leave a urine sample and will only be medicated if the culture confirms a urinary tract infection. Similarly, a patient with abdominal pain who might be observed with serial examinations will more likely undergo a computed tomography scan if seen first in the emergency department.

Relying on emergency rooms to provide primary healthcare for the uninsured is clearly a lose-lose situation. The patients themselves experience poorer health outcomes and lost wages, whereas the system suffers from the cost of overly conservative medical decisions.


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