In 2008 I posted on the famous RAND Health Insurance Experiment: 1974 to 1982 the US government spent $50 million to randomly assign 7700 people in six US cities to three to five years each of either free or not free medicine, provided by the same set of doctors. … people randomly given free medicine in the late 1970s consumed 30-40% more medical services, paid one more “restricted activity day” per year to deal with the medical system, but were not noticeably healthier! (
The authors say they primarily designed the study to measure hospitalization rates, so they may not have had the statistical power for detecting changes in health outcomes. Also may help explain why they didn't have the best analysis design for estimating the effects on health outcomes. Here are a few quotes from the paper:
Our primary outcomes were insurance and hospital utilization at 18 months (midline) and 3.5 years (endline) after insurance access. Secondary outcomes included insurance enrollment; other utilization metrics, such as the inability to use insurance and outpatient surgeries (endline only); and multiple categories of health.[...]
Our target sample size, 2,250 households per group, ensured 80% power to detect a 25% change in hospitalization rate across groups at the 5% significance level[...]
[This study] has limitations. First, the study was designed to be powered to detect a change in the hospitalization rate, not necessarily changes in health outcomes. Recent research has shown that samples sized in the millions may be required to find effects on rare outcomes
Medicine is for sick people. Access to medicine no more makes you healthy than access to the Internet makes you well-informed, or public schooling makes you educated.
I shell out $610/mo. for health insurance so I won't be bankrupted by a car wreck or cancer diagnosis, and to lower costs for the fat, old, reckless, and hypochondriac, and cover the rent-seeking imposed by an archaic, dysfunctional tort system.
Ironically both the lab leak hypothesis and the pangolin theory of the genesis of Covid would mean the the pandemic was started due to the demand for healthcare.The lab was cataloging viruses to help the medical system deal with them and pangolins are part of traditional Chinese medicine
This result should be sensitive to the prevailing standard of living. Rich people who have to pay for their own treatment will tend to buy anything important (and, probably, more besides); offering them additional free treatment will not improve the outcome. But poor people might not have been able to afford valuable treatment, if they had to pay for it themselves. Thus it is significant that this study was done in India, a much poorer country than the U.S.: even the lower standard of living in India is sufficient for people to pay for the health care that is really valuable.
I'm confused by the criteria of analysis. It seems obvious to me that having more access to medical care for after the fact health issues doesn't improve metrics in health issues cared for via preventative medicine. Was there actually any expectation these two were related?
I mean, comparing these two things feels like a study concluding that having more access to car insurance doesn't measurably reduces car theft. But why should it? From the perspective of those who get car insurance the goal isn't not to have their cars stolen, it's to have a new-ish car in hands, if theirs gets stolen, without paying the full price for a car, plus discounts on maintenance and other things. Analogously, with health insurance the goal isn't to have better health in general, it's not to pay the full cost of treatment, or any cost at all, if one gets injured or ill.
Now, sure, both types of insurance companies try to convince people to be better at the preventative side of things. Health ones by suggesting emphatically the insured to eat healthier, stop smoking etc., while charging more for people with previous health issues. Car ones by giving instructions on safe driving, subsidizing a few car-theft-preventing trinkets, and also charging more for people with a historic of bad car-related incidents.
So what I suppose may be concluded from such studies is that health insurance companies are very bad at convincing people to have better preventative health attitudes, at least when compared to car insurance companies, which seem to have some effectiveness in convincing people to do less of the things that cause car loss and car damage.
That's useful knowledge, sure, but it doesn't seem actually to be saying much. If anything, it basically confirms something health professionals have been saying for decades: that much more effort should be put into preventative medicine, from early childhood in schools, up into adulthood and old age. But that's about it.
I think we need to be careful about what we conclude here. Surely the people without insurance still received some health care, possibly substantial amounts. This result is about the added benefit of the health care they wouldn't have paid for out of their own pocket. One purpose of insurance is to prevent other results of having to pay for medical care, not just to provide additional care, that could account for the improvement in depression.
They collected data on 82 health outcome variables, in different experimental conditions. Then they analyzed that data by running >600 separate statistical tests (while adjusting for multiple comparisons) and counting how many were statistically significant. They also did some test on the overall distribution of the >600 p values.
That's throwing away a lot of information.
If getting health insurance only has a very small effect on whether a person fainted in the past 4 weeks, and a very small effect on whether someone develops eyesight problems, and so on for a bunch of other outcome measures, then this analysis isn't aggregating those effects into a total overall benefit. It's just saying that each of these effects is small - so small that this study is underpowered to distinguish any one of them from zero.
Right, that doesn't surprise me too much. What I'd expect the benefits of medical coverage to mostly be are quality of life improvements. I mean I guess I'd expect some health benefits in the us context from statins and other bp type meds but things like cancer etc tend to get treated (at least in us) regardless and only extend life by a little (when they don't, as in much prostate cancer..or maybe colon.. potentially reduce it). Indeed, the hospital care exposes ppl to lots of germs.
But, in addition to the stress concerns, one of the big benefits of having insurance is getting relief from pain, discomfort and (in rich countries) psychiatric treatment (depression etc).
Still I always thought best arg for universal health coverage is simply as a mechanism for wealth transfer with political plausibility.
The authors say they primarily designed the study to measure hospitalization rates, so they may not have had the statistical power for detecting changes in health outcomes. Also may help explain why they didn't have the best analysis design for estimating the effects on health outcomes. Here are a few quotes from the paper:
Our primary outcomes were insurance and hospital utilization at 18 months (midline) and 3.5 years (endline) after insurance access. Secondary outcomes included insurance enrollment; other utilization metrics, such as the inability to use insurance and outpatient surgeries (endline only); and multiple categories of health.[...]
Our target sample size, 2,250 households per group, ensured 80% power to detect a 25% change in hospitalization rate across groups at the 5% significance level[...]
[This study] has limitations. First, the study was designed to be powered to detect a change in the hospitalization rate, not necessarily changes in health outcomes. Recent research has shown that samples sized in the millions may be required to find effects on rare outcomes
Medicine is for sick people. Access to medicine no more makes you healthy than access to the Internet makes you well-informed, or public schooling makes you educated.
I shell out $610/mo. for health insurance so I won't be bankrupted by a car wreck or cancer diagnosis, and to lower costs for the fat, old, reckless, and hypochondriac, and cover the rent-seeking imposed by an archaic, dysfunctional tort system.
You're welcome.
Ironically both the lab leak hypothesis and the pangolin theory of the genesis of Covid would mean the the pandemic was started due to the demand for healthcare.The lab was cataloging viruses to help the medical system deal with them and pangolins are part of traditional Chinese medicine
Is this sarcastic?
See also comments on Hacker News: https://news.ycombinator.co...
Just canceled my insurance! A great new future of wealth awaits!
This result should be sensitive to the prevailing standard of living. Rich people who have to pay for their own treatment will tend to buy anything important (and, probably, more besides); offering them additional free treatment will not improve the outcome. But poor people might not have been able to afford valuable treatment, if they had to pay for it themselves. Thus it is significant that this study was done in India, a much poorer country than the U.S.: even the lower standard of living in India is sufficient for people to pay for the health care that is really valuable.
I'm confused by the criteria of analysis. It seems obvious to me that having more access to medical care for after the fact health issues doesn't improve metrics in health issues cared for via preventative medicine. Was there actually any expectation these two were related?
I mean, comparing these two things feels like a study concluding that having more access to car insurance doesn't measurably reduces car theft. But why should it? From the perspective of those who get car insurance the goal isn't not to have their cars stolen, it's to have a new-ish car in hands, if theirs gets stolen, without paying the full price for a car, plus discounts on maintenance and other things. Analogously, with health insurance the goal isn't to have better health in general, it's not to pay the full cost of treatment, or any cost at all, if one gets injured or ill.
Now, sure, both types of insurance companies try to convince people to be better at the preventative side of things. Health ones by suggesting emphatically the insured to eat healthier, stop smoking etc., while charging more for people with previous health issues. Car ones by giving instructions on safe driving, subsidizing a few car-theft-preventing trinkets, and also charging more for people with a historic of bad car-related incidents.
So what I suppose may be concluded from such studies is that health insurance companies are very bad at convincing people to have better preventative health attitudes, at least when compared to car insurance companies, which seem to have some effectiveness in convincing people to do less of the things that cause car loss and car damage.
That's useful knowledge, sure, but it doesn't seem actually to be saying much. If anything, it basically confirms something health professionals have been saying for decades: that much more effort should be put into preventative medicine, from early childhood in schools, up into adulthood and old age. But that's about it.
I think we need to be careful about what we conclude here. Surely the people without insurance still received some health care, possibly substantial amounts. This result is about the added benefit of the health care they wouldn't have paid for out of their own pocket. One purpose of insurance is to prevent other results of having to pay for medical care, not just to provide additional care, that could account for the improvement in depression.
If so, maybe you could get their data and do a better job of analysis.
They collected data on 82 health outcome variables, in different experimental conditions. Then they analyzed that data by running >600 separate statistical tests (while adjusting for multiple comparisons) and counting how many were statistically significant. They also did some test on the overall distribution of the >600 p values.
That's throwing away a lot of information.
If getting health insurance only has a very small effect on whether a person fainted in the past 4 weeks, and a very small effect on whether someone develops eyesight problems, and so on for a bunch of other outcome measures, then this analysis isn't aggregating those effects into a total overall benefit. It's just saying that each of these effects is small - so small that this study is underpowered to distinguish any one of them from zero.
Right, that doesn't surprise me too much. What I'd expect the benefits of medical coverage to mostly be are quality of life improvements. I mean I guess I'd expect some health benefits in the us context from statins and other bp type meds but things like cancer etc tend to get treated (at least in us) regardless and only extend life by a little (when they don't, as in much prostate cancer..or maybe colon.. potentially reduce it). Indeed, the hospital care exposes ppl to lots of germs.
But, in addition to the stress concerns, one of the big benefits of having insurance is getting relief from pain, discomfort and (in rich countries) psychiatric treatment (depression etc).
Still I always thought best arg for universal health coverage is simply as a mechanism for wealth transfer with political plausibility.
:)