Here is more evidence that the uninsured fare worse than the insured. Including trauma patients in the emergency room. 

The AP's Carla Johnson reported on a troubling study published in Archives of Surgery, Downwardly Mobile: The Accidental Cost of Being Uninsured.  She writes that "uninsured [adult] patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance."

Under a 1986 law known as EMTALA (Emergency Medical Treatment and Active Labor Law), anyone who shows up in an emergency room needing emergency treatment will receive treatment to stabilize him or her. That statute is intended to "prevent hospitals from rejecting patients, refusing to treat them, or transferring them to ‘charity hospitals' or ‘county hospitals' because they are unable to pay or are covered under Medicare or Medicaid."

Despite adjusting for race, gender and age, the researchers concluded that the uninsured still have an 80 percent greater chance of dying than those with insurance. Even in a setting where equitable treatment is mandated by federal law, the uninsured still experience significantly worse health care outcomes.

What gives?

The researchers offer several possible explanations for this glaring disparity:

• Uninsured patients may experience treatment delay. (A separate study published in the Journal of Pediatric Orthopaedics demonstrates that children with private insurance receive more timely care than children with public insurance or no coverage at all.)
• Uninsured trauma patients are less likely to be admitted to the hospital and receive fewer services during their admission when compared to insured trauma patients.
• Institutions treating a higher proportion of uninsured patients may have fewer available resources.
• Lower health literacy, and less ease and skill in communicating with ER physicians or other health care providers, may play a role.  (In 2008, 88 percent of all uninsured adults in America did not have a college degree.)

"I'm really surprised," Dr. Eric Lavonas of the American College of Emergency Physicians and a doctor at Denver Health Medical Center told the AP, "It's well known that people without health insurance don't get the same quality of health care in this country, but I would have thought that this group of patients would be the least vulnerable."

This leads us to the "accidental" part of the disparity question.

The researchers do acknowledge the limits of their study and that some of their explanations for the gap are speculative. They note that "treatment is often initiated before payer status is recognized; thus, this provokes the question of whether differences exist in processes of care during the hospital stay." (Meaning not the first encounter with the ER but the ongoing care.)

But even in a setting where equitable care is "not only expected but mandated by law" and providers may be unaware of their patients' insurance status -- health outcomes of the uninsured are significantly worse. There must be some other explanation. Or might it just be an "accidental cost" of being uninsured in the United States?

"This is another drop in a sea of evidence that the uninsured fare much worse in their health in the United States," explains senior author Dr. Atul Gawande. As the study concludes, these unintended consequences that the uninsured pay may just be "too high to continue to overlook."