Sunday, January 16, 2011

Myth Diagnosis:
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.

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.”

Megan McArdle elaborates:

So allow me, maybe, to be the first. I'm afraid I'm not confident about any number. All of these studies suffer from unobserved variable bias, which is to say, the uninsured are not like the rest of us. (The long term uninsured, I mean; the short term uninsured are not a large problem for society). There are all sorts of reasons that people end up uninsured, but most of them are correlated with much poorer health outcomes, and only some of them end up recorded in our surveys.

To give you an example of what I mean, one of the two studies that went into the most commonly cited number--the roughly 20,000 a year figure from the Institute of Medicine and the Urban Institute--found that the highest mortality was not associated with being uninsured, but being on a government health care program. (the other excluded those patients). This was true even after they'd run all their controls. Given that the bulk of the coverage expansion in both the Senate and the House plans comes from Medicaid expansion, this is a little disturbing.

But how likely is it that Medicaid is killing people? Possible, I suppose, but not really all that likely. Medicaid and Medicare patients, too, are not like the broader population. The authors in fact recognized this fact in their paper, pointing out that these patients have higher rates of disability--but then failed to address the obvious question this raised about their data on the uninsured. This problem plagues almost all of the studies on mortality and the uninsured...

That doesn't mean I'm prepared to say that no one dies from lack of insurance. The data is messy, and the studies often contradict each other. 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.
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