Category: Medicine

On health insurance and mortality, you'll find Megan's further thoughts (which I agree with) here (and now here).  Neither of us is saying the real net effect is zero.  Also check out Matt, Ezra, Austin Frakt, all of whom make good points. 

Overall I'd like to see more numbers in the health care debate.  If the Obama plan spends $90 billion extra a year on coverage and saves/extends 10,000 lives a year (a plausible estimate, in my view), that is $9 million a life, a rather underwhelming rate of return.  That's a very gross comparison because life extension is not the only benefit and the $90 billion is not the only cost.  Still, as a starting point for analysis I don't think it makes the plan look better.  Keep also in mind that many of the newly covered people are bumping others back into the queue, since the overall supply of medical care isn't going up and may even be declining.

If you did a simple cost-benefit comparison, the Obama plan vs. a simple extension of Medicaid, more R&D through the NIH, and some targeted public health expenditures, I believe the latter would win hands down.  And the latter seems more politically feasible too.  It avoids the mandate, the unworkable and ridiculously low penalties for those who don't sign up for insurance, and the awkwardly high implicit marginal tax rates imposed by the subsidy scheme.  It probably involves fewer corporate and "back room" deals.

In its favor, the Obama plan makes it easier to become an entrepreneur without losing health insurance coverage.  I doubt if that's enough to swing the balance, but in any case it's worth thinking about.  

Please don't argue that the Obama plan saves money.  Even if you believe that (I don't), here we are talking about the marginal impact of one subcomponent of the overall plan.  That subcomponent does cost money.

When it comes to the Obama plan, the easy targets are stupid or hypocritical Republicans.  The hard target is why the plan should beat the alternative reforms I've outlined above or perhaps other ways of spending the money.  I'd like to see more people take on the hard target rather than the easy.

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. 

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.

There is a growing awareness among researchers, including advocates of quality measures, that past efforts to standardize and broadly mandate "best practices" were scientifically misconceived. Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality, the federal body that establishes quality measures, acknowledged that clinical trials yield averages that often do not reflect the "real world" of individual patients, particularly those with multiple medical conditions. Nor do current findings on best practices take into account changes in an illness as it evolves over time. Tight control of blood sugar may help some diabetics, but not others. Such control may be prudent at one stage of the malady and not at a later stage. For years, the standards for treatment of the disease were blind to this clinical reality.

Orszag's mandates not only ignore such conceptual concerns but also raise ethical dilemmas. Should physicians and hospitals receive refunds after they have suffered financial penalties for deviating from mistaken quality measures? Should public apologies be made for incorrect reports from government sources informing the public that certain doctors or hospitals were not providing "quality care" when they actually were? Should a physician who is skeptical about a mandated "best practice" inform the patient of his opinion? To aggressively implement a presumed but still unproven "best practice" is essentially a clinical experiment. Should the patient sign an informed consent document before he receives the treatment? Should every patient who is treated by a questionable "best practice" be told that there are credible experts who disagree with the guideline?

That's Jerome Groopman, the full article is here, interesting throughout, and I thank someone — alas I have mislaid the email address – for the pointer.  My apologies to the person who sent this in.

It opened not long ago, find it here, as I write it's at 33.9 for passage before July and it has been rising from 20 or so.  Bernanke, by the way, is back up to 93.

Megan McArdle recommends:

Raise the Medicare tax by half a percentage point, and eliminate the tax-deductibiity of health insurance benefits for people making more than $150K a year in household income, $100K for singles.  Then make the federal government the insurer of last resort.  Any medical expenses more than 15% or 20% of household income, get picked up by Uncle Sam.

Ezra Klein recommends:

Medicare buy-in between 50 and 65. Medicaid expands up to 200 percent of poverty with the federal government funding the whole of the expansion. Revenue comes from a surtax on the wealthy.

And that's it. No cost controls. No delivery-system reforms. Nothing that makes the bill long or complex or unfamiliar.

My earlier thoughts are here.