Clarification on health care

by on February 12, 2010 at 8:43 am in Medicine | Permalink

Over at Twitter, Matt Yglesias asks:

Do rightwingers really believe that US health insurance has no mortality-curbing impact?

I don't speak for "right-wingers," but I'll say this:

1. I genuinely don't know what to believe.  And I often toy with the idea of an "innovation-maximizing" health care policy, so that future coverage is more effective.

2. I am commonly excoriated by people (not Matt) for not supporting government-subsidized universal health insurance, yet few if any of these people grapple seriously with the best evidence.

3. I live in a country where the extension of health insurance is a major issue, and a major budgetary issue, yet much of the discussion is in an evidence-free zone.

4. I don't view it as incumbent on me to come up with the final answers in this debate or even a provisional stance.  It's incumbent on the people pushing coverage plans to make the case for what they are doing and so far they haven't.  I do recognize that medical bankruptcy is a separate set of issues and that greater coverage will significantly lower financial risk.  That said, the appropriate response on the health issue is not to change the topic and start talking about bankruptcy.

My original post is here

Andrew February 12, 2010 at 9:09 am

The Left-Wingers have been trying to sell us this line:
“US healthcare is not worth the money, let’s spend more.”

Why wouldn’t Right-Wingers counter with:
“US healthcare is not worth the money, let’s not spend more.”

William February 12, 2010 at 9:48 am

Am I the only one who tunes out (usually subconsciously) whenever I see words like “rightwingers” or “lefties” ?

David February 12, 2010 at 10:18 am

What does “mortality-curbing impact” mean? Does that imply a Pareto-type improvement where everyone at least does as well as they are doing now, but some live longer?

A plan that simultaneously increases coverage and reduces costs will almost certainly help some people live longer and shorten the lives of others. The former group is politically powerless, and its champions want to pretend like the latter group doesn’t exist; of course, the latter group does exist, it isn’t politically powerless, and is easy to scare and mobilize. Therein lies the impasse.

That’s even before we get into the question of technological change, technology adoption, etc… Interesting post.

Eapen Thampy February 12, 2010 at 10:36 am

I thought it was interesting, and not necessarily incorrect, that you say over “at” twitter, not over “on” twitter.

Pat L February 12, 2010 at 10:43 am

Taking these studies as valid, it seems at least one of the following is true:
1) Access to health care has little effect on mortality
2) Health insurance has little effect on access to care.
3) Neither of the above, but there is another variable obscuring the effects.

1 seems unlikely, so it would have to be either 2 or 3. If it’s 2, then we should focus on extending coverage for financial reasons, and bringing our health care system costs into line with the rest of the first world. To rule out 3, well, this is why “more study is needed” is such a common conclusion.

d4winds February 12, 2010 at 10:49 am

re: ” It’s incumbent on the people pushing coverage plans to make the case for what they are doing and so far they haven’t.”

Excellent point. Does it apply for a $3tn war in Iraq also?

floccina February 12, 2010 at 11:31 am

If a treatment restores health most Americans can amortize a couple of hundred K.

Eric February 12, 2010 at 11:41 am

“Excellent point. Does it apply for a $3tn war in Iraq also?”

Yes, actually. I am curious about where you got the 3tn statistic.

Miller February 12, 2010 at 11:58 am

Pat L,

If it’s 2, then we should focus on extending coverage for financial reasons, and bringing our health care system costs into line with the rest of the first world.

Huh? How does “Health insurance has little effect on access to care” imply that we should focus on extending coverage at all?

Miller February 12, 2010 at 12:11 pm

What kind of warped vision to people have to believe that the burden of proof lies with those that want to change things?

The kind that thinks evidence and rational analysis are more important for resolving complex public policy issues than emotion and wishful thinking.

dale February 12, 2010 at 1:33 pm

Evidence and rational thinking do not mandate the burden of proof to those that want to change things. You could just as easily say that the burden is to provide evidence and rational thinking that the current system works.

anon February 12, 2010 at 2:10 pm

OK, dale, we have n alternatives:

(1) continue with status quo;
(2) change policy to new policy #1;
. . .
(n) change policy to new policy #(n-1).

Which of the above should *not* have the burden of proof? You must pick one — failure to pick is an implicit choice of option (1).

Devon Herrick February 12, 2010 at 2:48 pm

In the long run, mortality is 100%. So what we are really talking about is whether health insurance increases longevity. Numerous studies find correlation between premature death and being uninsured. Yet, I would argue lack of coverage is more of an intervening variable rather than a cause (technically the disease is the cause). The same conditions that led to being uninsured likely have greater affect on health status than the lack of coverage (these include: lack of risk aversion, discounting future utility at too great a discount rate, poor lifestyle choices, unhealthy behaviors, lower education, etc.) Lacking coverage may be little more than a symptom of the underlying cause that ultimately led to a premature death.

An interesting read on insurance and health status: http://www.john-goodman-blog.com/does-lack-of-insurance-cause-premature-death-probably-not/

Kent February 12, 2010 at 4:26 pm
cmholm February 12, 2010 at 4:44 pm

Mr. Cowen’s post, abstracted:

“I don’t trust any of the existing evidence, everybody else’s arguments are faith-based, and it’s not my job to clear things up.”

IMO, this is the clarion call of a lazy “skeptic” in defense of any status quo. Unlike mere comment authors such as me, Mr. Cowen is paid to write about economics. If he’s wants to maintain credibility, he needs to either 1) attempt to illuminate the topic, or 2) write about something else.

What he’s offering here is FUD, which isn’t something I’d expect from someone with his CV.

Miller February 12, 2010 at 5:19 pm

dollared,

The evidence is clear that lack of insurance is a cause of (ealier) mortality in at least tens of thousands of people annually in the US, and the cause of hundreds of thousands of otherwise avoidable bankruptcies in the US.

No it isn’t. The findings of studies on the relationship between both health insurance and health, and health insurance and economic security, are all over the place. Some studies find a strong relationship, others a weak one, and still others virtually no relationship at all.

George Williams February 12, 2010 at 6:10 pm

Here is some evidence for this discussion:

http://theincidentaleconomist.com/consequences-of-uninsurance/

dollared February 12, 2010 at 7:21 pm

@Miller, @George Williams has some excellent data. So does Ezra Klein. http://voices.washingtonpost.com/ezra-klein/2010/02/will_health-care_insurance_sav.html#more Plus you have the uncontroverted fact of hundreds of thousands of bankruptcies, and the overall productivity consequences of those include depressed future income for offspring.

Hopefully this persuades you that the available data, while imperfect, suggests that there is a significant cost for failing to insure a significant percentage of our population.

Sameer February 12, 2010 at 8:25 pm

While the question discussed by Megan in her article and blog post is interesting, I don’t think the purpose of health-care is primarily and simply to avoid death. Also since life-saving emergency care is not denied to anyone, lack of health insurance does not translate into lack of life-saving care. Lack of health insurance probably causes lack of primary and preventive care which is cheaper in 2 ways. 1>It avoids costly treatments by preventing and/or detecting illness earlier 2> It prevents the loss of individual productivity caused by untreated illnesses.

So the right question to be asked would be – ‘What are the costs of not-having a substantial number of people insured as compared to the benefits?’. I am thinking only in terms of costs/cost savings to the government here since we are talking about expanding coverage by subsidizing the cost of health insurance. I wonder if my logic makes sense and if any such studies have been done? Is it more costlier in the long term to have lost revenue (by lost productivity and lost individual income, increased cost of tax-payer funded emergency care, increased cost of treatment for illnesses of people who are uninsured for long period before they become eligible for medicare etc.) or is the benefit of subsidizing health insurance and requiring mandates greater?

dollared February 12, 2010 at 9:03 pm

Miller, I’ll try to help you with some data one more time. There are millions of personal bankruptcies every year in the US. The #1 cause or all causes for those bankruptcies, however, is uncovered medical bills, heaped on under- or un-insured people. Here is just one study: 60+% of all personal bankruptcies in US in 2007 involved unpaid medical expenses. http://voices.washingtonpost.com/health-care-reform/2009/06/new_study_shows_medical_bills.html. Here’s another, saying 46% of all bankruptcies: http://www.msnbc.msn.com/id/6895896//.

As for the fact that you don’t like Ezra’ sources on mortality, well, you found one metastudy that you didn’t link to. I looked up your sources by name and they said in 2008 1)the current studies indicate that health insurance coverage should be expanded, but they did not isolate for all variable, since no current study is perfect; 2) but most studies lead us to believe that increasing coverage would improve health nationwide 3) we need people to fund more studies like the kind we do (so we can get more research funding):
http://arjournals.annualreviews.org/doi/pdf/10.1146/annurev.publhealth.28.021406.144042?cookieSet=1

“After reviewing the evidence
on this question, we reach three conclusions. First, many of the
studies claiming to show a causal effect of health insurance on health
do not do so convincingly because the observed correlation between
insurance and good health may be driven by other, unobservable factors.
Second, convincing evidence demonstrates that health insurance
can improve health measures of some population subgroups,
some of which, although not all, are the same subgroups that would
be the likely targets of coverage expansion policies. Third, for policy
purposes we need to know whether the results of these studies
generalize. Solid answers to the multitude of important questions
about how specific health insurance policy options may affect health
seem likely to be forthcoming only with investment of substantial
resources in social experiments.
399
Annu. Rev

So again, what exactly is this thread about? Nobody is disputing the facts, other than McMegan, you and Tyler.

Tom February 12, 2010 at 9:29 pm

“So again, what exactly is this thread about? Nobody is disputing the facts, other than McMegan, you and Tyler.”

Dollared, and others, assertions, no matter how much we REALLY believe them are not facts. Just because it REALLY feels right does not make it a fact.

dollared February 13, 2010 at 2:36 am

Miller, you have not a leg to stand on. Take two facts: 10,000+ premature deaths/year, and hundreds of thousands of bankruptcy filings caused by medical bills/year. Those facts are incontrovertible from the studies.

The evidence is clear on the range of 10,000+ premature deaths per year. Yes, it is absolutely true that the studies do not have the precision of a controlled experiment where 1,000,000 people, spread perfectly evenly across all economic strata, ethnic groups and religious persuasions, and divided in perfect proportion to our current urban/suburban/rural population distribution, are divided into two equally sized groups, and one group is given complete health insurance coverage and the other zero, and then measurements are taken for 20 years. But the accumulated data in the cited studies show that it is far more likely that the mortality exceeds 10,000 deaths per year, than it is less than 10,000 deaths per year. Not one of those studies, and not one of the meta-studies, indicates anything else. It is simply a logical fallacy that a complaint that one cannot tell if a number is 18,000 or 45,000, means that it is likely to be less than 10,000.

And the bankruptcy data is absolutely, completely incontrovertible: 1.4 million nonbusiness bankruptcy filings in 2009. The studies indicate that medical issues, including bills, were a major causal factor in 50-67% of them. That’s a population of 700,000-850,000. Even if you isolate out other factors, you would end up with uncovered medical bills causing at least, what, 200,000 to 500,000. The data is not perfect, but the numbers are so large that the conclusions are there to be had if you are not being deliberately obtuse. Which, of course, is precisely what you are being.

And these numbers aren’t very hard to believe, across a nation of 300M.

I’m sorry you don’t think the data is precise enough. God help any of you deniers if you acted like this in your personal or professional life: “I’m sorry boss, I didn’t have enough data to determine if all of our female customers had stopped buying our Chevy Novas and started buying Hondas because they get better mileage, they’re more reliable and they have a better feature set for young woman buyers. So I’ve commissioned a ten year longitudinal study to examine the behavior of a group of 200,000 women from ages 18 to 30. It will only cost about $30 Million, we can just stop advertising for hte next two years to pay for it. We’ll make a decision about the new Nova model in, say, 8 years from now, when we have good preliminary data.”

Nah, you would all be failures if you behaved like that. Instead, you guys are just doing the Global Warming dodge: “we need more data, since we don’t want to do anything.”

So I’ll tell you: in the real world, real people make decisons based on intelligent analysis of imperfect and incomplete data. There is plenty of data on the two subjects we are discussing. It all points in one direction, although there is a pretty wide variation in how strongly it points. And you – you are picking on the data because you don’t support the actions required by the data.

You know people are dying and families are collapsing – you just don’t want to feel that any action is required to prevent that from happening. It’s that simple.

allison February 13, 2010 at 10:04 am

–The #1 cause or all causes for those bankruptcies, however, is uncovered medical bills, heaped on under- or un-insured people. Here is just one study: 60+% of all personal bankruptcies in US in 2007 involved unpaid medical expenses.

The question is not the relevant one. The question should be what percentage of people with medical expenses over X end up in bankruptcy, not what percentage of bankruptcies involve medical expenses.

I bet 100% of bankruptices include unpaid car expenses. Do car loans cause bankruptcy? Should we give everyone car loan insurance?

dollared February 14, 2010 at 1:59 am

Miller, I am not inventing facts. And not only is your logic suspect, but you keep referring to things that you don’t link to, like imaginary “debunkings” of bankruptcy studies.

Here is the reality for adults: there are widely available data and estimates. They indicate a set of possible outcomes from the studies. If they were business strategy cases, you would use a Monte Carlo analysis (“there is a 20% chance that 100,000 extra people die early per year, and a 40% chance that 50,000 people die early per year, and a 60% chance that 40,000 people die early per year.”)

You know what? You take the aggregated data from the studies, and then you do that Monte Carlo analysis. You will find that there is a greater than 50% chance that 10,000 or more people die early per year. That was my point.

You are asking that somebody give you a number that we are 100% sure is the number of people who die early per year. The only number that can be is one derived from a detailed analysis of every death in the past year. So, since nobody has the funding for that, the answer is: some very low number.

But no one makes decisions on that basis. If you did that in real life, you’d never apply for a job, because nobody would give you 100% odds of landing it.

Tell me (as if I didn’t already know): do you think there is anthropogenic global warming? What do you think we should do about it?

dollared February 16, 2010 at 2:37 pm

@ Miller: The data is there, and yes, it is irrefutable. Here’s more:

“After conducting thorough reviews of the research, IOM in 2002 and 2009, McWilliams in 2009, and Hadley in 2003 all concluded that the clear preponderance of findings from well-designed studies strongly link insurance coverage and mortality rates. McCardle erred by presenting the Kronick study as the gold standard for research on this issue to the exclusion of all studies published since 1994 that go against her argument.

Of course, the number of adults who die because they lack health insurance cannot be defined with absolute precision. Our earlier report found that improving the IOM’s methodology would increase the number of estimated deaths by more than 15 percent. And a recent Harvard Medical School study concluded that, because health care now controls disease more effectively than in the past, the lack of health insurance increases mortality by 40 percent, rather than the 25 percent estimate used by the IOM and our earlier study.” http://voices.washingtonpost.com/ezra-klein/

Bottom line, you see the data, but you would rather people die than adjust your prejudices.

Time for you to go back to disputing the existing of AGW on environmentalist sites. Have fun.

Raducu November 25, 2010 at 9:30 am

US has many issues when it comes about the healthcare system.And it is sad to see that a country like America has this problems and much more the people who live in that country have to suffer because of this problem.There will always be a side which will say that the system is okay and an other side will say the system has gaps.drug rehab facilities

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