Crozet Annals of Medicine: Insuring Survival


It looks like spring is here for good after a brief cold snap. Good news for sure for gardeners, maybe less so for ER docs. The influx of pollen-triggered allergies and asthma is not too challenging to deal with, but the spike in trauma is as noticeable as the spikes of my asparagus shoots lately emerging. I walked into a recent shift to find four major trauma patients arriving within 15 minutes of each other. I saw two broken necks in a single shift. Fortunately both patients did well and had no paralysis.

I work at a level one trauma center. We are certified and equipped and staffed to care for the most critically injured and we never say no to a trauma transfer from another hospital. We are also an indigent care hospital, one of only two in the state. We are designated to receive Medicaid support from the state and federal governments in recognition of our disproportionate share of indigent or charity care. Consequently we receive lots of requests from other ERs to accept their insured and uninsured patients for further care. So I am in a unique position to observe a fundamental effect that health insurance has on life or death.

A study published in the Archives of Surgery in 2009 analyzed data from 2.7 million patients recorded in the National Trauma Data Bank from 2002 through 2006. The researchers concluded that uninsured trauma, patients who are hospitalized have a mortality (death) rate that is 50 percent higher than insured patients who are hospitalized for trauma. If you are unlucky enough to be young, (18-30 years old) uninsured and hospitalized for trauma, your mortality is an astonishing 89 percent higher than your hospitalized trauma contemporaries who have insurance. This is after adjusting for severity of injuries, race, sex, and other illnesses. The only difference is insurance. No one knows why this is. This effect is seen in non-trauma illnesses as well. The uninsured have a 40 percent increase in mortality over the insured, according to a study published in the American Journal of Public Health in 2009. This, too, is after adjusting for smoking, obesity, alcohol use and other illnesses. This is 45,000 deaths a year due to lack of insurance, or one death every 12 minutes.

I can speculate on the causes of this increased mortality: delays in care for trauma patients due to transfers, lower health literacy and compliance with care in uninsured patients, subtle biases in caregivers including physicians, less aggressive testing and treatment for the uninsured (this has actually been shown in other studies), but truly we do not know the mechanism(s) for this alarming increase in death.

The Supreme Court has just concluded hearing oral arguments over the constitutionality of requiring all citizens to purchase some form of health insurance. One of the objections was that forcing young healthy people to buy insurance was an unneeded financial imposition that served to support the elderly’s more expensive care. Of course if you are young and in a car crash, insurance apparently may just save your life. That does not change the constitutional question, but it does point out that we have a public health crisis that is costing lots of people their lives and we need to provide universal health care insurance somehow.

After penning this column I was working in the ED seeing a patient from the nearby town of Louisa with a one-year history of severe abdominal pain. I asked him if he had ever seen a doctor for this. His reply was eerily accurate.

“No, I don’t have any insurance. In Louisa you are pretty much dead if you don’t have insurance,” he observed.

I am sure he thought he was speaking metaphorically.


  1. Thank you for your informative and insightful columns. They are on my must read list whenever I see a new issue of the gazette. I think you may have a book in your future!

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