Megan on Med

How Many People Die From Lack of Health Insurance? … The most recent available study, which also had the largest sample and controlled for the most variables, found no effect at all. … The left is predictably fond of the study which got the largest number [dead], 45,000 a year.  Unfortunately, its authors are political advocates for a single-payer system, who also helped author the notorious studies on medical bankruptcies.  Those studies are very shoddily done. … The right, meanwhile, shuns the subject like the plague.  It will not do anyone’s career any good to be attached to an argument that sounds like the health care equivalent of “let them eat cake”.

That is Megan at her blog.  More from her in the Atlantic:

Ezra Klein declared that Senator Joseph Lieberman, by refusing to vote for a bill with a public option, was apparently “willing to cause the deaths of hundreds of thousands” of uninsured people. … In the ensuing blogstorm, … few people addressed the question that mattered most: …  If we lost our insurance, would this gargantuan new entitlement really be the only thing standing between us and an early grave?  Perhaps few people were asking, because the question sounds so stupid. Health insurance buys you health care. Health care is supposed to save your life. So if you don’t have someone buying you health care well, you can complete the syllogism. …

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. …

The only truly experimental study on health insurance, a randomized study of almost 4,000 subjects done by Rand and concluded in 1982, found that increasing the generosity of people’s health insurance caused them to use more health care, but made almost no difference in their health status. … Analyses of the effect of Medicare, which becomes available to virtually everyone in America at the age of 65, show little benefit. In a recent review of the literature, Helen Levy of the University of Michigan and David Meltzer of the University of Chicago noted that the latest studies of this question “paint a surprisingly consistent picture: Medicare increases consumption of medical care and may modestly improve self-reported health but has no effect on mortality, at least in the short run.” …

We should have had a better handle on the case for expanded coverage—and, more important, the evidence behind it—before we embarked on a year-long debate that divided our house against itself. Certainly, we should have had it before Congress voted on the largest entitlement expansion in 40 years. Unfortunately, most of us forgot to ask a fundamental question, because we were certain we already knew the answer.

Forgot?!  This is no random memory failure.  For many decades health economists have known that the best available evidence shows little or no relation at the margin between med and health.  The health economists advising all the major sides have long known this.  When the data is this noisy, there will always be exceptional studies, and as Megan says, the left prefers to cite exceptions that find more med tied to more health; the right prefers to avoid the issue.

These tactics are far from random accidents; neither side wants to contradict the US public, with their religious-level faith in the healing powers of medicine.  If we were considering a vast new grocery store or car entitlement, the public would hardly “forget” to wonder if that would really give us more nutrition or a faster commute.  But the US public has little religious-style fervor on grocery stores or cars.

How often do you see theists wonder if God is really as good as folks say, or patriots wonder if their nation really deserves their allegiance?  That’s how often you will see the US public question the value of medicine.

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  • jz

    Another way to frame the question:

    How many uninsured die for lack of healthcare? A: a few , very few
    How many insured have their death prolonged by healthcare? A; Many many

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  • Chroma

    Of course what’s ironic is that this data would also appear to strongly support the creation of a single payer system, or at least a system with heavy government involvement, since it suggests that government technocrats might actually be able to make much more efficient decisions about health care spending than individual consumers.

    And, in fact, this is precisely what we see in many countries with single payer systems, as compared with the US: they spend a lot less on medical care, and achieve equivalent or better health outcomes.

  • Anonymous

    Since you’re confident that medicine has little to no effect, would you care to make it interesting? How much would you charge to forego all medicine for the next five years? How much would you charge to limit yourself to a $2000/year budget? I’m sure I can get a few people to pitch in if a respected economist will put his health where his mouth is.

    • It’s a tempting offer. What are the odds that (1) I will come down with a serious health problem in the next 5 years; and (2) the problem is one which will respond well to medical treatment?

      Maybe one in 10,000? I guess I prefer not to take that risk on a personal level. But I would think it’s a pretty small risk.

    • Chris

      Anonymous, the claim is not that medicine has no effect on health. The claim is that health insurance has no effect on health.

      • Robin’s claim is far broader. As he put it: “For many decades health economists have known that the best available evidence shows little or no relation at the margin between med and health.”

        If true, that claim shouldn’t be startling just to those who believe in medicine; it should be startling to those who believe in economics. Just about anyone who can afford it purchases health insurance and spends money at the margin for medical products and services. Neither signaling nor rational choice nor rational ignorance would seem to explain this behavior.

        It’s much easier to tell a rational choice or signaling story about health care denialism: isn’t it startlingly clever? wouldn’t it be economically rational for those who can already afford their own health insurance to lobby against measures that would tax their income for the benefit to others? Etc.

  • Hal Finney

    One nitpick. As I understand statistics, the more things you control for, the more likely you are to find a negative result. Now Megan writes about Kronick’s research, “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” and yet he found a negative result (no effect). Her wording makes it sound like controlling for more things (“even” mobile homes) makes the result more impressive. Actually it makes the result less impressive.

    I’m not saying the result is wrong, just that the rhetorical presentation is a little misleading.

  • Chroma, I don’t see how med’s marginal impotence shows that govt technocrats have the ability or inclination you suggest. Medicare is govt already.

    Anonymous, I said “at the margin.”

    Hal, Kronick’s paper also shows how estimates change as you reduce the number of controls.

    • Chroma

      And Medicare spending per capita is close to private per-capita spending, which suggests dramatically higher efficiency when you consider that it covers an older population that is, statistically, much sicker.

      But there are limits to how efficient Medicare can be when the market in which it is buying services has been so heavily distorted by the irrationalities of the private health insurance market. You really have to look at countries that apply single-payer universally to see the full benefit.

  • Lord

    Chroma is correct. Comparing life expectancy vs public care and private care indicates public care is quite effective and efficient while private care is almost a total waste (maybe the hospital food tastes better though).

  • Bill

    You should go to the Marginal Revolution site and look at the comments debunking this article, including research that goes the other way.

    Also, remember that the indigent get medical care through Medicaid; if you have a normal or higher income, you have insurance. The group just above Medicaid indigent and below those able to afford insurance is the group that should be looked at and which this “study” misses.

    If you want to do comparability, look at countries with public health coverage and those that do not have it.

    I would have thought this would not have been posted given the references on the Marginal Revolution site of more and contrary studies.

  • Bill

    Here is one of the posts of from the Marginal Revolution site debunking the article:

    “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.”

    • Chris

      That paper is suggestive, but hardly conclusive.

      It has a serious flaw in that they don’t run the most basic possible check of methodology: run the same study, searching for a discontinuity at 64, 63 or 66 (and finding none). I don’t see how the referee let them publish without this.

      But lets assume the discontinuity exists and is robust. The discontinuity is more than 2x larger than could be reasonably explained by people shifting from uninsured to insured. This implies that in addition to insurance, there is also a mystery factor involved in the discontinuity.

      To determine the effect of health insurance, we must figure out whether this mystery factor explains 50% or 100% of the discontinuity.

      • Bill

        Let’s call the mystery factor Toothpaste.

      • Chris

        I’ll interpret your non sequitur to mean that you realize your study is inconclusive, but you do not wish to lose status by acknowledging it.

      • Russell Johnston

        Let’s call the mystery factor “more money for food”

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  • Unnamed
  • Unnamed

    Here is Ezra Klein’s reply. He says “At its base, [Megan McArdle’s column] takes a methodological difficulty (it’s hard to measure mortality) and blows it into something approximating a conclusion (insurance coverage has no effect on mortality),” and then reviews some evidence for the importance of insurance (including the QJE study mentioned by Bill).

  • Megan has yet another post trying to explain what she means.

  • Dave

    The study doesn’t address the most common use of insurance, to treat non- fatal disease.
    Just as an example, my ophthalmologist couldn’t get a patient into the local nonprofit hospital to treat glaucoma as needed. So the guy will eventually go blind, but may live a long time.
    Being affluent and well insured, my friends are always going to the hospital for joint replacements, tests, cardiac stents, cataract or gallbladder surgery or to have some suspicious breast lump excised. All these things improve quality of life but don’t markedly extend it.

    On the other hand, if a non insured person needs emergency treatment or just wants to visit a family doctor she doesn’t need health insurance.

    If he gets cancer or some really bad chronic problem ,a person usually goes bankrupt and, gets on Medicaid and gets treated that way. So, all this study shows is that the system we have now is pretty good at keeping people alive. I doesn’t not show that it keeps people healthy.

    There are several studies out there that show that people don’t prioritize their health when it comes to spending their dollar. If there are increased co-payments or lack of insurance coverage, they reduce their doctor’s visits. Thus, if preventive care is effective, it will be more effective if paid for by a third party. Then that leads to the question of a persons responsibility for their own welfare, and destiny, etc.

    • Doug S.

      What he said.

    • valter

      That was my first reaction, too.

      Aren’t there any studies that at least use QALYs instead of mortality?

  • First problem among both sides of the debate is the purposeful confusion between healthcare and health insurance.

    Second, and probably more important is the false notion that a publicly funded healthcare system would provide the same level of healthcare that is available today in the semi-private system.

    Any argument that does not first (and always) address this second issue is at best incomplete, and worst, just plain wrong if not deceitful.

  • Lo Statuz

    I’m not quite ready to buy Robin Hanson’s whole “showing that you
    care” theory, but it does explain a lot. Maybe someone can be
    persuaded to do some fMRI. If the same parts of the brain light
    up when people think about medicine as when they think about
    religion, and they’re different parts from what lights up when
    people think about other health-related activities, that would be

  • Russell Johnston

    I can’t quite understand why more people aren’t interested in WHY the effect might be neutral – the best bet is probably that drugs are vastly more harmful in their long term effects than we now know (or could know.) But maybe Doctors also tend to inadvertently “approve” bad life style choices by the rude things they don’t say. Or maybe we take better care of ourselves when we know others won’t.

    Of course, there could also be a rural effect – the farther you are from a health clinic, the farther you are from shift work or a bar.