LETTER FROM AMERICA/Patrick Smyth: A chilling report this week from a US non-profit group, the Institute of Medicine, provides a graphic illustration of the realities of care in the richest country in the world.
According to the study, some 18,000 adults in the US die prematurely each year because they are uninsured and can not get access to proper health care.
Care Without Coverage: too little too late looks at the plight of the 30 million working Americans - one in seven - whose employers don't provide insurance cover and who do not qualify for the safety net of Medicare, available only to those on welfare.
Lack of cover, which can be prohibitive for a family whose employer does not pay, in some cases prevents diagnosis or delays it, and can lead to life-threatening complications.
The report, commissioned by the National Academy of Science, estimates the extra death toll among people with high blood pressure at 1,400, with breast cancer at 400 to 600, and HIV, at 1,500. Nearly half of the deaths are in the 55 to 64 age group.
And it finds that uninsured people with colon cancer face a 50 per cent higher chance of death, while trauma victims are both less likely to be admitted to hospital and are one-third more likely to die of their injuries.
Among diabetes sufferers, for example, some 25 per cent are going without testing for two years - five times as many as among the insured.
And one study finds that the risk of death for a patient after arriving at a hospital is 37 per cent higher among the uninsured, reflecting both the evidence they are likely to be more ill before they attend hospital and the finding that they will receive fewer services once there if not covered.
"If you lack health insurance coverage you're going to have a poor health status, a greater chance of dying early and your quality of life is not going to be as good because of poor health care," Mary Sue Coleman, co-chair of the committee that wrote the report, told reporters.
"Because we don't see many people dying in the streets in this country, we assume that the uninsured manage to get the care they need, but the evidence refutes that assumption," said Ms Coleman, president of the Iowa Health System and University of Iowa, Iowa City.
One study included in the report followed 4,700 Americans for at least 13 years. The death rates were 18.4 per cent for those without insurance and 9.6 per cent for the insured.
Another study compared California residents who lost health benefits with those who did not and those with benefits only part of the time.
Over two years, 22 per cent of people with no coverage experienced a major decline in their health.
Sixteen per cent of people with benefits part of the time noted a deterioration in health, compared with 8 per cent of those who were covered all the time.
Meanwhile, spiralling insurance costs are creating shortages of obstetricians and gynaecologists.
Doctors are leaving the baby-delivery business or leaving states where juries award lawsuit "lottery prizes" to parents with handicapped babies, said Dr Thomas Purdon, president of the American College of Obstetricians and Gynaecologists (ACOG). "Liability insurance has become unaffordable or even unavailable," he says.
Fees vary widely by region. Premiums average only $12,000 a year for Nebraska obstetricians and gynaecologists, but $208,000 in areas of Dade and Broward counties of Florida. In parts of Texas and Nevada, rates recently quadrupled, Dr Purdon says.
Parents with brain-damaged babies typically win the largest claims, averaging nearly $1 million.
But awards can soar far higher. A recent Philadelphia case ended with a $100 million decision.
The result, according to USA Today, is that in Pennsylvania, a quarter of Ob-Gyns say they have stopped or are planning to stop delivering babies.