"During a nationally broadcast forum Monday evening on faith and politics Sen. Hillary Clinton (D.-N.Y.) attacked the free market and told listeners in that order to attain energy independence and provide universal health coverage, it would be necessary to 'take away from some people.'" The Senator was quoted as saying:

"An uninsured person who goes to the hospital is more likely to die than an insured person," Clinton said. "I mean, that is a fact. So what do we do? We have to build a political consensus. And that requires people to give up a little bit of their own turf in order to create this common ground."

Well.

Let’s examine this statement from the reigning queen of the New Age of American socialism. First of all, let’s look at the statement primae facie. Cannot one assume that the uninsured, for whatever inequity that may or may not be "society’s fault" (unemployment, drug dependence, promiscuity, etc) may be sociologically different from the patient with insurance? Perhaps, for the sake of argument, the uninsured patient was found by EMS comatose under a bridge from a drug overdose. Perhaps, to take the example to another level, the "uninsured" patient who succumbs in the hospital had been homeless and had a month-old cellulitis of the leg or a gangrenous arm from needle-sharing prior to admission and died of subsequent sepsis. Perchance, the "uninsured" had AIDS or hepatitis C or any of myriad other viruses that can suppress the immune system which made hospital care particularly dangerous owing to the risk of hospital-acquired infection. So, in general, people who are "uninsured" may have many medical, sanitary and nutritional conditions that will certainly make them high risk patients in a hospital setting. The fact that they do not have pre-paid insurance coverage would be a nice straw man on which to blame this obvious discrepancy.

I suspect that those unfortunate patients who fall under Senator Clinton’s overly-broad category of "the uninsured" are separate for reasons that go far beyond the fact that they do not have Blue Cross/Blue Shield. To propose, as Senator Clinton appears to do, that "uninsured" patients are somehow treated differently (premature discharge, inadequate medical or professional management, discriminatory nursing care, etc) by hospitals and that this treatment contributes to or directly causes the supposed higher mortality rates is irresponsible even as campaign rhetoric. Personally, as a physician, it offends my ethical sensibilities for a candidate to assert that the care I would offer a patient is based on whether or not they have insurance. But don’t look for the American Medical Association or anyone to call out the Senator on this. That would be impolitic.

Finally, let us examine the initial premise that, according to Senator Clinton’s phrase, "I mean, that is a fact." Well, is it? According to the University of Pennsylvania, I am not sure it is. In an analysis they did of over 286,000 patients, they found statistically insignificant differences in hospital mortality between insured and uninsured patients in New York and New Jersey hospitals. Between 1994 and 1996, mortality rates for uninsured patients actually declined in New York hospitals and were statistically unchanged in New Jersey hospitals.

There are a wealth of other studies on outcomes for uninsured patients versus insured patients. While there are often differences in outcomes, the vast majority of instances are related to the individual factors I previously mentioned. I will only quote one here:

"This paper compares uninsured hospital patients with privately insured patients in terms of severity of illness on admission, emergency department use, leaving the hospital against medical advice, length of stay, and in-hospital mortality and morbidity rates. This cross-sectional study includes 29,237 admissions to 100 US hospitals in 1993 and 1994. We found that uninsured patients are sicker, indicating that hospitals should expect uninsured patients to have increased service needs. Our results indicate that the uninsured exhibit higher likelihood of leaving against medical advice, shorter lengths of stay and poorer health outcomes suggest that the uninsured may not be receiving necessary care. Further studies are needed." [Emphasis mine]

The simple fact which, while not making as good - grammar aside - a sound bite as "I mean, that is a fact," is that when you compare apples and oranges, there will always be differences. Senator Clinton needs to know what she means before she goes for the quick made-for-headlines quote.