Insurance and risk of death for neonates

From HSR, “Increased Risk of Death among Uninsured Neonates“:

Objective: To estimate the contribution of health insurance status to the risk of death among hospitalized neonates.

Data Sources: Kids’ Inpatient Databases (KID) for 2003, 2006, and 2009.

Study Design: KID 2006 subpopulation of neonatal discharges was analyzed by weighted frequency distribution and multivariable logistic regression analyses for the outcome of death, adjusted for insurance status and other variables. Multivariable linear regression analyses were conducted for the outcomes mean adjusted length of stay and hospital charges. The death analysis was repeated with KID 2003 and 2009.

Principal Findings: Of 4,318,121 estimated discharges in 2006, 5.4 percent were uninsured. There were 17,892 deaths; 9.5 percent were uninsured. The largest risks of death were five clinical conditions with adjusted odds ratios (AOR) of 13.7–3.1. Lack of insurance had an AOR of 2.6 (95 percent CI: 2.4, 2.8), greater than many clinical conditions; AOR estimates in alternate models were 2.1–2.7. Compared with insureds, uninsureds were less likely to have been admitted in transfer, more likely to have died in rural hospitals and to have received fewer resources. Similar death outcome results were observed for 2003 and 2009.

Conclusions: Uninsured neonates had decreased care and increased risk of dying.

Let’s own up front that this was not a randomized controlled trial, and therefore we’re not proving that uninsurance causes death. But this was a pretty large study using a nationally representative database of hospitalized children. And not having insurance was a significant risk factor for death.

The most likely predictors were significant neonatal issues, like intrauterine growth retardation, hypoxia, intraventricular hemorrhage, congenital malformation, or necrotizing enterocolotis. But the next most significant predictor was uninsurance. Unininsurance beat sepsis, obststrical complications, multiple births, and respiratory distress syndrome. Uninsurance was also a within-hospital predictor, meaning that even in the same hospitals, not having insurance was significantly associated with death.

Yes, it’s difficult to tease out the interaction and individual contributions of race, socioeconomic status, and uninsurance. All of those likely come into play. But you can’t look at results like this and just wave them away because you can’t build a perfect study and do a perfect analysis. Neonates with insurance are less likely to die in the hospital. I think that’s worth considering as we debate insurance expansions in the next year.


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