How many people die from lack of health insurance?

Megan McArdle has an excellent post on that question and here is her column.  Here is one startling bit:

To my mind probably the single most solid piece of evidence is this:  turning 65–i.e., going on Medicare–doesn't reduce your risk of dying.  If lack of insurance leads to death, then that should show up as a discontinuity in the mortality rate around the age of 65.  It doesn't.  There are some caveats–if the effects are sufficiently long term, then it's hard to measure, because of course as elderly people age, their mortality rate starts rising dramatically.  But still, there should be some kink in the curve, and in the best data we have, it just isn't there.

And this:

The possibility that no one risks death by going without health insurance may be startling, but some research supports it. Richard Kronick of the University of California at San Diego’s Department of Family and Preventive Medicine, an adviser to the Clinton administration, recently published the results of what may be the largest and most comprehensive analysis yet done of the effect of insurance on mortality. He used a sample of more than 600,000, and controlled not only for the standard factors, but for how long the subjects went without insurance, whether their disease was particularly amenable to early intervention, and even whether they lived in a mobile home. In test after test, he found no significantly elevated risk of death among the uninsured.

I agree with her conclusion:

Intuitively, I feel as if there should be some effect.  But if the results are this messy, I would guess that the effect is not very big.


Are there any peer-reviewed articles criticizing the bankruptcy studies and the "45,000" study? She dismisses them, and I wonder whether her criticisms are borne of her own bias or are backed up by the scholarly community at large.

An alternative is that moral hazard is a bigger problem than previously thought; enough 64-year-olds are putting off unhealthy activities to make a kink disappear.

I mean, if health insurance (not just government-provided insurance!) has truly such a marginal impact on mortality, why bother? People do consume private insurance.

Or do we just have a social safety net that - despite all its flaws - is already intelligent enough to stave off mortality but still incentivise people to buy private insurance?

Lots of interesting possibilities here. I look forward to bloggers analyzing it.

Wrong, wrong. The real high cost of health events fall on a tiny fraction of the population, a share so small that there is no surprise that lack of insurance does not affect survival.
The error of Obama admin. is to fail to emphasize the extreme concentration of health care costs in any given year. Ten percent of health care users account for a year's 80 percent (nearly) of health spending. But there is no predicting who gets caught. Gamblers go without insurance and most win. Only an insurance requirement can answer this issue of extreme cost concentration. The administration backed away from even mentioning this risk issue. Ay Caramba.

Well for an economics reporter you'd think she would have at least seen this (QJE 124(2) 2009), which finds exactly the discontinuity in mortality she claims doesn't exist:

"The health insurance characteristics of the population changes sharply at age 65 as most people become eligible for Medicare. But do these changes matter for health? We address this question using data on over 400,000 hospital admissions for people who are admitted through the emergency room for "non-deferrable" conditions -- diagnoses with the same daily admission rates on weekends and weekdays. Among this subset of patients there is no discernible rise in the number of admissions at age 65, suggesting that the severity of illness is similar for patients on either side of the Medicare threshold. The insurance characteristics of the two groups are much different, however, with a large jump at 65 in the fraction who have Medicare as their primary insurer, and a reduction in the fraction with no coverage. These changes are associated with significant increases in hospital list chargers, in the number of procedures performed in hospital, and in the rate that patients are transferred to other care units in the hospital. We estimate a nearly 1 percentage point drop in 7-day mortality for patients at age 65, implying that Medicare eligibility reduces the death rate of this severely ill patient group by 20 percent. The mortality gap persists for at least two years following the initial hospital admission."

Another theory is that non-emergency health care is not as effective at reducing mortality as we would like to think.

Oh, and don't forget, the indigent get Medicaid.

So, you want to focus on the group that is above Medicaid indigency and below an income level that would support purchasing private insurance.

There has been a lot of nonsense written on this subject -- by reputable and not so reputable folks, most of whom are not economists. I reviewed a lot of this for Health Affairs a while back at here:

I think I am missing something (maybe I need to read the article). Just because an individual is uninsured doesn't mean they aren't getting treatment. The question is how much does that treatment cost (i.e. administered in an emergency room), how is it being paid for and ultimately what is their quality of life (which is not necessarily measured by years of life).

"going on Medicare--doesn't reduce your risk"

... how is Medicare *not* insurance? What am I missing? The other studies might be relevant, but this tidbit supports claims of the effectiveness of Medicare (cost issues aside).

Best regards,

--Another theory is that non-emergency health care is not as effective at reducing mortality as we would like to think.

We can reduce mortality? Really? The rate is stil l00% on the planet.

But yes, I think the main idea: that modern non emergency medicine cures stuff is really not particularly substantiated.

We've got antibiotics, and those have been around a long time. We've got stents, and those seem to actually keep people alive that would otherwise have died within in year. Surgeries can remove things, but cure them?

But what else does medicine cure?

Non emergency medicine is about treating symptoms. It isn't about root causes. It isn't about curing underlying issues. The procedures and tests and medications are all about reactions to already occurring things, and so the idea that beyond antibiotics, medicine really has a big marginal value per dollar is not well established.

Does lack of insurance somehow cause diabetes and other chronic illness? The uninsured certainly have worse control over chronic conditions, but to attribute the health outcomes solely to insurance status is to ignore the factors associated with they have these illnesses in the first place: education, behavior (diet, exercise, etc.), environment, and genetics.

In John Goodman's blog post (which he was nice enough to link to a hundred times above -- ha!), he notes that the O'Neills study found higher mortality rates among Medicaid enrollees than in the uninsured. Medicaid isn't killing people any more than lack of insurance is causing chronic illness.

There's this thing called biological plausibility...

A couple possibilities come to mind here:

a. Short term vs long term effects:

An uninsured guy having a heart attack will be treated at the local ER. More broadly, where there are effective lifesaving treatments for short-term crises, insured and uninsured people both get them, though the uninsured person ends up with a much bigger bill. So maybe the main impact of not having insurance is longer term, as deferred maintenance catches up with you?

One reason to doubt this, at least to my non-medically-trained mind, is that most maintenance isn't all that expensive. My understanding is that the care of a top-notch cardiologist will do a lot less to prevent a heart attack than quitting smoking and working out regularly, for example.

b. Risk balancing

Perhaps much of the difference in care you get with insurance involves expensive tests/procedures whose health benefits are more-or-less balanced by their risks. Some of those improve quality of life (hip replacements), others are looking for disease or problems that will then require intervention (nuclear stress tests). In that case, it may be that much or all of the added lifespan of better healthcare is spent on the lost lifespan from medical errors or complications from the procedures that are done. That's especially plausible for something like hip replacements, right? I mean, you're explicitly accepting some risk of death to make your life better.

Just one story:

I have a friend who was without heath insurance and never went to the doctor for at least 10 years before he hit medicare eligibility. During this time he looked healthy but for the last 5 years or so he had a problem in his legs, for which he took aspirin every day. The aspirin helped and he was mobile and basically healthy he would invite a bunch of his friends to meet for lunch each Friday. As soon as he hit 65 he was happy to be on medicare and went to the doctor. The doctor diagnosed his leg problem as due to an aneurysm in one artery that goes to his legs. The doctor wanted to treat the aneurysm surgically but said his heart was too weak and so gave him a heart bypass first. They did the heart bypass and in few months then did surgery on aneurysm. It has been about a year he is less mobile and unable to have lunch with his friends and appears to be far less health over all. They just did surgery for prostate cancer on him.

He deteriorated so rapidly after getting medicare that I just keep thinking about what I read in Dr Nortin Hadler's book "The Last Well Person" and Robin Hanson's work and wondering if he would have been better off avoiding doctors.

People have been dying forever, but medicare was only introduced in the 1960's. Isn't there before/after data that was studied here?

Are there any peer-reviewed articles criticizing the bankruptcy studies and the "45,000" study?

Here is Dranove and Millenson's study criticizing the Himmelstein et al study that found that medical problems contribute to 54% of personal bankruptcies: Medical Bankruptcies: Myth vs Fact. D&M contend that Himmelstein's analysis is seriously flawed and that a proper analysis of the same data yields a number of 17%. D&M's study was published in Health Affairs, which I believe is a peer-reviewed (and highly respected) medical journal.

It is important to point out that indigents who seek care in emergency rooms or otherwise are not "free riders." First of all, since some 50% of healthcare is provided by tax dollars, they have presumably paid their share. Secondly, the true "free riders" are those who enjoy health insurance through their employer at taxpayer expense. The result is that most middle-class Amerikans have been subsidized by the indigent, NOT vice versa.

Isn't there a selection bias here?

I.e. if there is a strong risk of death correlated with not having insurance, then people who are not insured are less likely to live to turn 65 in the first place, thus, most people turning 65 were more likely to have been insured their whole life, and/or be the healthiest of the uninsured.

If US health insurance really has little or no mortality-curbing impact, what accounts for this? In other words, are you saying people without insurance are still getting adequate health care, or that health care isn't important to curbing mortality?

I suppose another way of asking the question is,

Would you chose to go without health insurance and/or medical care when you are 65 (or 55 or 45)?

My answer is a resounding NO!

My quality of life would suffer. I'd be alive but I would not be happy. I'd rather die of a heart attack after playing 3 hours of tennis than of pneumonia after years in a wheel chair because my joints can no longer support me.

If Tyler and Megan are not willing to forgo their medical insurance/care based on these studies, then perhaps the studies are answering the wrong questions.

Or maybe the obvious is just too difficult to see.


That's not rephrasing the original question, it's asking a different one. One argument for some kind of fundamental reform of the medical industry in the US is that uninsured people are dying needlessly. This argument has been made in blogs and in headlines often. So it's worth asking how many people are dying, if any, because of this.

You also conflate medical insurance with medical care, and entirely ignore questions of cost.

Since it seems plausible that insurance saves some, the stats suggest that it probably kills others. A nice fat insurance policy is a good excuse to do some interesting procedures. Medicine very likely did more harm than good before 1950 - maybe it still does.

Two separate areas: Healthcare - Medical Benefits Insurance.

Two different actuarial concepts: Morbidity - Mortality

Also, you might (that's a maybe) learn something from the actuarial tables
of mortality extension as age survival is achieved.

For many years in the U S, as best I recall, rate of male deaths per thousand in the age bracket from 38 to 48 was higher than that of those who reached age 65. I think that bracket has since moved.

You might also say that getting a life insurance policy extends life. Look at the CRVM and select and ultimate reinsurance tables. Take a look at the first three years mortality rates. Of course there is a reason.

"Chronic life threatening issues that medicine can fix are extremely rare before the 65 Medicaid age limit."

I am suprised to read something so untrue on these pages. Hypertension and high cholesterol are just two examples of extremly common chronic conditions, which are deadly (and costly) if not treated, but easily and inexpensively treated with modern medicine. Similarly, screening for colon, cervical or breast cancer is relatively cheap, easy and has a profound impact on both mortality and quality of life. There is a massive difference in the outcomes of individuals who receive basic preventative care such as this, and those that do not. The uninsured certainly fall into the latter group.

Furthermore, I am similarly surprised that so much of the discussion on this subject ignores quality of life, which ought to be incorporated into any analysis.

It is easy to change the cause of death, but it is very difficult to delay death. The major changes that have decreased mortality and increased life expectancy are farming (vs hunting), washable clothing, clean water, antibiotics and job safety. Most of the recent gains in life expectancy are probably due to better prenatal care than anything afterward. We are probably at the stage where the cost benefit is outside the medical field. Reductions in accidental deaths, homicides, and suicides would probably due more to increase life expectancy in the US than more medical care.

It would seem that morbidity would be nearly as important, it's simply more difficult to quantify than mortality. Inconvenient data are also important, and may be crucial.

Is this really supposed to be such a skinny article? My brain doesn't feel like registering this information by reading it vertically.

I'm a bit amazed that so many people here think poverty level people get Medicaid. I am 47 my husband 56 neither of us is insured and both of us became unemployed within the past year and a half. We ARE NOT eligible for Medicaid. We WOULD be IF we were NOT citizens of this country or if we were over 65 or if one of us were expecting a child. Maybe other states are different but this is what we have been dealt.
Right now I am suffering from severe gallstones and can not get the surgery because hospital emergency rooms are ONLY required to stabilize you not cure you!
I am slowly deteriorating. I now have jaundice and more or less if someone doesn't volunteer their medical expertise this is my death sentence.

How many people go bankrupt WITH insurance. My company wants to charge $1000/m for a family. I make $1600/m - if I were to get insurance we would surely go bankrupt and fast!

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