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http://www.latimes.com/news/nationworld/nation/la-sci-trauma-uninsured17-2009nov17,0,4308260.story

Uninsured trauma patients are much more likely to die

The risk of dying from traumatic injuries is 80% higher for those 
without any insurance, a study says. ER physicians say they're 
surprised by the findings.

By Karen Kaplan

November 17, 2009

Patients who lack health insurance are more likely to die from car 
accidents and other traumatic injuries than people who belong to a 
health plan -- even though emergency rooms are required to care for 
all comers regardless of ability to pay, according to a study 
published today.

An analysis of 687,091 patients who visited trauma centers nationwide 
from 2002 to 2006 found that the odds of dying from injuries were 
almost twice as high for the uninsured than for patients with private 
insurance, researchers reported in Archives of Surgery.

Trauma physicians said they were surprised by the findings, even 
though a slew of studies had previously documented the ill effects of 
going without health coverage. Uninsured patients are less likely to 
be screened for certain cancers or to be admitted to specialty 
hospitals for procedures such as heart bypass surgery. Overall, about 
18,000 deaths each year have been traced to a lack of health 
insurance.

But insurance status isn't supposed to be a factor for trauma 
patients. The Emergency Medical Treatment and Active Labor Act, 
passed by Congress in 1986, guarantees that people brought to 
emergency rooms get all necessary treatment no matter what kind of 
insurance they do -- or don't -- have.

The research team from Harvard University and Brigham and Women's 
Hospital in Boston used information from 1,154 U.S. hospitals that 
contribute to the National Trauma Data Bank. The team found that 
patients enrolled in commercial health plans, health maintenance 
organizations or Medicaid had an equal risk of death from traumatic 
injuries when the patients' age, gender, race and severity of injury 
were taken into account.

The risk of death was 56% higher for patients covered by Medicare, 
perhaps because the government health plan includes many people with 
long-term disabilities, said Dr. Heather Rosen, who led the study 
while she was a research fellow at Harvard Medical School.

The risk of death was 80% higher for patients without any insurance, 
the report said.

The researchers also did a separate analysis of 209,702 trauma 
patients ages 18 to 30 because they were less likely to have chronic 
health conditions that might complicate recovery. Among these younger 
patients, the risk of death was 89% higher for the uninsured, the 
study found.

Rosen, now a surgical resident at USC's Keck School of Medicine, said 
the group expected to find at least some disparity based on insurance 
status. But she said the group was surprised at the magnitude of the 
gap.

Dr. Frank Zwemer Jr., chief of emergency medicine for the Hunter 
Holmes McGuire VA Medical Center in Richmond, Va., said he was "kind 
of shocked."

"We don't ask people, 'What's your insurance?' before we decide 
whether to intubate them or put in a chest tube," said Zwemer, who 
wasn't involved in the research. "That's not on our radar anywhere."

The researchers offered several possible explanations for the 
findings. Despite the federal law, uninsured patients often wait 
longer to see doctors in emergency rooms and sometimes visit ERs at 
several hospitals before finding one that will treat them. Other 
studies show that, once they're admitted, uninsured patients receive 
fewer services, such as CT and MRI scans, and are less likely to be 
transferred to a rehabilitation facility.

Patients without insurance may have higher rates of untreated 
underlying conditions that make it harder to recover from trauma 
injuries, the researchers said. They also may be more passive with 
doctors and nurses because they don't interact with them as often. 
All of these factors could influence whether a trauma patient is able 
to recover.

But the link could also be coincidental, the authors acknowledged. 
Perhaps the hospitals that have fewer resources at their disposal 
also happen to see the most uninsured patients, they said.

The types of injuries may differ too, Zwemer said. Gunshot and 
stabbing victims -- frequently younger people involved in crime -- 
were much more likely to die from their wounds than other trauma 
patients tracked in the study. These people are generally uninsured, 
but the type of injury -- not insurance status -- is the reason for 
their higher fatality rates, he said.

More research is needed to figure out whether lack of insurance 
actually harms trauma patients or whether the data simply reflect a 
correlation, said Dr. A. Brent Eastman, chairman of trauma at Scripps 
Memorial Hospital in La Jolla.

The issue is particularly relevant as Congress and the Obama 
administration weigh various measures to reduce the number of 
uninsured Americans, Eastman wrote in a short critique that 
accompanied the study.

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