Rational Arguments

You may remember that a few months ago, I – along with some other people – were a bit upset about an article Megan McArdle wrote in the Atlantic.  Austin Frakt got a few of us together, and we wrote a letter to the editor.  Unfortunately, they didn’t publish it.  More unfortunately, none of the other letters they did publish accomplished the same goals as ours.  So we’re posting it anyway.  I’m still not inclined to re-start my subscription.

To The Atlantic Editor:

Megan McArdle’s March 2010 article, “Myth Diagnosis,” distorts the scientific record in asserting that, “Quite possibly, lack of health insurance has no more impact on your health than lack of flood insurance.” Citing a tiny fraction of the literature on this topic, she concludes that we should know far more about the relationship between health insurance and mortality before considering major reforms to the health care system. But we already know vastly more than McArdle lets on.

For example, she characterized one study, which did not find a decrease in mortality risk due to insurance, as “what may be the largest and most comprehensive analysis yet done of the effect of insurance on mortality.” That sounds as if this single study is determinative. Yet no study in a social science could be. In truth, that insurance and the access to care it facilitates improves health and reduces mortality risk is as close to an incontrovertible truth as one can find in social science.

Viewed as a whole, the body of evidence shows that this relationship is well established. Last year, comprehensive literature reviews conducted by the Institute of Medicine and published in the Milbank Quarterly concluded that the overwhelming majority of well-conducted studies have found important health benefits of insurance, including lower risk of mortality. In addition to quasi-experimental research, several observational studies by leading researchers that controlled for a robust set of characteristics have demonstrated a 35-43% greater risk of death within 8-10 years for adults who were uninsured at baseline and even higher relative risks for older uninsured adults with treatable chronic conditions, such as diabetes and hypertension. These and other relevant studies are described in three online summaries posted in response to McArdle’s article—by Stan Dorn on Ezra Klein’s blog at the Washington Post (tinyurl.com/StanDorn), Harold Pollack on The New Republic’s The Treatment blog (tinyurl.com/HPollack), and by J. Michael McWilliams on Austin Frakt’s blog The Incidental Economist (tinyurl.com/JMMcWill).

But McArdle did not make her readers aware of this body of evidence. Instead, she cherry-picked work that supported her conclusion, ignoring every study published since 1994 that is inconsistent with her argument. It is one thing to argue that we should reassess proposed approaches to health reform. It is quite another to misrepresent a body of work in support of that conclusion and further mislead readers that such work does not exist.

No one could object to The Atlantic‘s support for a wide range of opinion columns. But The Atlantic is a respected, widely read home to intellectually honest and rigorous journalism. One hopes that, before publishing an article like McArdle’s at a key juncture of the national debate over health reform, the magazine’s editors would have made sure that the article fairly reflected the available evidence. Sadly, McArdle’s article did not come close to meeting that standard.

Austin Frakt, PhD
Assistant Professor of Health Policy and Management
School of Public Health
Boston University

Stan Dorn, JD
Senior Fellow
Urban Institute

Jack Hadley, PhD
Professor and Senior Health Services Researcher
Dept. of Health Policy and Management
George Mason University

Aaron E. Carroll, MD, MS
Associate Professor of Pediatrics
Director, Center for Health Policy and Professionalism Research
Indiana University School of Medicine

Lisa I. Iezzoni, MD, MSc
Professor of Medicine, Harvard Medical School
Director, Mongan Institute for Health Policy
Massachusetts General Hospital

An eagle eyed reader pointed me to this study:

Purpose

Uninsured children face health-related disparities in screening, treatment, and outcomes. To ensure payer status would not influence the decision to provide emergency care, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, which states patients cannot be refused treatment or transferred from one hospital to another when medically unstable. Given findings indicating the widespread nature of disparities based on insurance, we hypothesized that a disparity in patient outcome (death) after trauma among the uninsured may exist, despite the EMTALA.

Methods

Data on patients age 17 years or younger (n = 174,921) were collected from the National Trauma Data Bank (2002-2006), containing data from more than 900 trauma centers in the United States. We controlled for race, injury severity score, sex, and injury type to detect differences in mortality among the uninsured and insured. Logistic regression with adjustment for clustering on hospital was used.

Results

Crude analysis revealed higher mortality for uninsured children and adolescents compared with the commercially or publicly insured (odds ratio [OR] 2.97; 95% confidence interval [CI], 2.64-3.34; P < .001). Controlling for sex, race, age, injury severity, and injury type, and clustering within hospital facility, uninsured children had the highest mortality compared with the commercially insured (OR, 3.32; 95% CI, 2.95-3.74; P < .001], whereas children and adolescents with Medicaid also had higher mortality (OR, 1.19; 95% CI, 1.07-1.33; P = .001).

Conclusions

These results demonstrate that uninsured and publicly insured American children and adolescents have higher mortality after sustaining trauma while accounting for a priori confounders. Possible mechanisms for this disparity include treatment delay, receipt of fewer diagnostic tests, and decreased health literacy, among others.

Here’s the gist – people wanted to see if being uninsured was associated with worse outcomes at the emergency room after trauma.  Because, you know, we have a universal system where everyone can get free care at the emergency room.  Or not.

The researchers looked at tons of data, almost 175,000 children injured between 2002 and 2006.  They controlled for race, injury severity score, sex, and injury type.  And even after doing that, children who were uninsured had more than three times the odds of dying from comparable injuries than children covered with private insurance.

So there you have it.  Being uninsured is associated with an increased risk of children dying, from injuries, in an emergency room.  Maybe someone should tell the people who claim there’s no evidence that uninsurance leads to a higher chance off death.

It’s unlikely you can get the whole article, because it’s probably behind a paywall, but it’s entitled, “Lack of insurance negatively affects trauma mortality in US children.”

Last week I was giving a lecture on quality in health care systems, and showed some slides on the pretty crappy mortality rates in a number of disease processes in the United States.  A student who was paying attention asked if differences in prevalence could account for differences.

Well, they can.  But the differences aren’t in the direction you’d think.  Check this out, from a McKinsey Global Institute report, “Accounting for the cost of U.S. health care: A new look at why Americans spend more“:

So on the left side, you’re seeing the cost of caring for different diseases in the US in order from most expensive to least.  On the right you’re seeing when the US has a lower (orange) or higher (blue) prevalence than comparable countries.

It’s not hard to see there’s more orange than blue.  So much so that reduced prevalences in the US should result in actual cost savings compared to other countries than costing more.  We have less disease, higher costs, and often still more death from those diseases.

How much more data do you need?  The US health care system just isn’t that good.

Many people think we have the best health care system in the world.  They’re wrong.  We have some of the best doctors in the world.  Some of the best hospitals.  Even some of the most advanced technology in the world.  But our health care system isn’t very good.

“Yet our survival rates for X are better!” people shout.  And while we can argue whether our ability to extend the life of a relatively small number of people a short period of time is the true hallmark of quality, it’s the use of survival rates instead of mortality rates that is even more telling.

Mortality rates are the number of people who die of a certain cause in a year divided by the total number of people.  For instance, that the mortality rate for people with lung cancer in the United States is 53.4 per 100,000 people.

Survival rates are something else entirely.  They calculate the percentage of people with a disease who are still alive a set amount of time after diagnosis.  The five year survival rate for people with lung cancer in the US is 15.6%.

But here’s the thing.  You can only decrease the mortality rate by preventing death, or preventing the disease.  That’s really it.  That’s a cure or a life extension.  Survival rate, however, can be increased by preventing death, preventing disease, or making the diagnosis earlier.

And there’s the rub.  Let’s say there’s a new cancer of the big toe killing people.  From the time the first cancer cell appears, you have 10 years to live, with chemo.  From the time you can feel a lump, you have five years to live, with chemo.  Let’s say we have no way to detect the disease until you feel a lump.  The five year survival rate for this cancer is about 0, because within five years of detection, everyone dies, even on therapy.

Now I invent a new scanner that can detect the cancer when only one cell is there.  Because it’s the United States, we invest heavily in those scanners.  Early detection is everything, right?  We have protests and lawsuits and now everyone is getting scanned like crazy.  Not only that, but people are getting chemo earlier and earlier for the cancer.  Sure, the side effects are terrible, but we want to live.

We made no improvements to the treatment.  We are making the diagnosis five years earlier, yet everyone is still dying five years after they feel the lump.  But our five year survival rate is now 100%!  Everyone is living ten years with the disease.  Meanwhile, in England, they say that the scanner doesn’t extend life and won’t pay for it.  Rationing!  That’s why their five year survival rate is still 0%.  U-S-A! U-S-A!

The mortality rate is unchanged.  The same number of people are dying every year.  We have just moved the time of diagnosis up and subjected people to five more years of side-effects and reduced quality of life.  We haven’t done any good at all.  We haven’t extended life, we’ve just lengthened the time you have a diagnosis.

Think this is far fetched?  Why do you think that in England women are screened by mammography every three years starting at age 50, yet in the United States the American Cancer Society recommends women are screened by mammography every year starting at age 40.  For a woman diagnosed with breast cancer in 2001, the five year survival rate in the US was 89.1%; in England it was 80.3%.  Go USA!

The mortality rates?  The American Cancer Society’s Cancer Facts & Figures 2009 reports it’s 25.0 per 100,000 women in the US and Cancer Research UK reports it’s 26.7 per 100,000 women in England.  Hard to believe we’re spending almost two and a half times per person for health care what they do over there.

(h/t Factcheck.org for some links)

UPDATE: This in no way means I’m opposed to mammography and/or early detection for breast cancer.  That can absolutely make the difference in outcomes.  But there is a point at which we go overboard.  We need to recognize that and find the sweet spot for screening.  Moreover, that’s not what this post is about.  It’s about cherry picking statistics to make us look better than we are.