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

I’ve been getting a lot of email asking about the new report from CMS.  You know the one.  Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” as Amended.  Yes, the report says that by 2019, the law will increase health care spending by 1%.

I’m confused. Some of you are emailing me as if this is some sort of vindication that you were right and I was wrong.  As if you’ve uncovered some hidden truth that the law will make things cost more.

Huh?

No one claimed that covering 30 million more people would cost less.  Some have claimed that it will slow cost growth.  The jury is still out on that.  But come on.  This is still a decent deal.  Ezra Klein shows it well through two charts:

The first looks at national health expenditures with and without the Affordable Care Act:

Now look at the change in the uninsured:

And that actually understates the case. Third Way, the centrist policy outfit, sent over its own analysis of the data. “The fact is that by 2019, national health spending per insured person will be $15,132 compared to $16,812 without the new law,” they write. “That’s 10 percent less spending per insured person than it would have been, according to the actuary’s report.”

You don’t have to love the law.  And it has flaws.  But this report hasn’t found a new one.

One of the most frustrating talking points against health care reform is that we don’t want to “rush”.  There’s no crisis.  We should scrap this and start over.   Go small.  Do little.

Then you see something like this:

The number of uninsured adults and children in California swelled by 25 percent between 2007 and 2009, according to a new report by researchers at the University of California, Los Angeles.

One quarter of the state’s population is now uninsured, according to the analysis, and less than half of those with insurance receive it through employers.

The increase, to 8.2 million from 6.4 million, is largely because of job loss during the recession, said Shana Alex Lavarreda, co-author of the study and director of health insurance studies at U.C.L.A.’s Center for Health Policy Research. The figures include all workers in the state regardless of immigration status.

In 2007, even before the economy’s collapse, the number of uninsured adults and children in California had reached more than six million, Dr. Lavarreda added.

One quarter of people.  Remember, everyone over the age of 65 has Medicare.  So the percentage of non-elderly without insurance is even higher.

By the way, the numbers of people also on public insurance also increased over this time.  All the net loss is from the private insurance system.  And insurance rates are going up and up and up.

How high is a crisis?  Does anyone think the economy issues are solved?  Is unemployment going away?

At what point do we say enough?

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 night I spoke as part of a panel on health care reform.  The main point I tried to get across was that our health care system is a mess.  It’s the costliest in the world, it gets nowhere near universal coverage, and it is surprisingly disappointing in terms of quality.  This is not news to readers of this blog.  Because it’s so bad, we need real reform.  Massive.  It needs to be big and it needs to be comprehensive.

If you listen to politicians on both sides of the aisle, you’d think we were getting that.  Those on the right claim this is a total government takeover of health care the likes of which have been seen only in their worst socialist nightmares.  Those on the left claim it’s going to revolutionize the system by covering everyone, reducing costs, and realigning the delivery system so that we get quality over quantity.

Not so much.  On either side.

I’m reading over the CBO report for the new and improved Senate Finance Committee bill.  Here’s an actual projection on how the bill will change insurance coverage over the next ten years:

Here’s what I want you to notice.  See the Employer line?  There are currently about 150 million people who have employer based insurance.  This plan will, after a decade, result in a net three million fewer people on employer based insurance.  We will expand Medicaid and SCHIP by 14 million.  We’ll get 23 million people into the insurance exchange.

The number of uninsured will drop 29 million, leaving another 25 million people under the age of 65 still uninsured.

This is socialism? This is comprehensive, massive reform?  Hah! Don’t get me wrong.  This is still a good thing; 29 million fewer uninsured people is better.  I imagine that the tighter regulations will help prevent underinsurance as well.

But let’s not kid ourselves.  A lot of those newly insured are getting coverage from safety net programs.  And the rest are going into the exchange to buy private insurance.  There is no massive government takeover.  Nor, however, is this comprehensive reform.  We will only have reduced uninsurance by about half and will still have more uninsured people than any comparable country.  Or costs will still be massive and rising fast.  And our quality will still likely hover around where it is now.

Yes, this is the most that any administration has ever gotten in terms of health care reform for the country at large.  But is this is really the best we can do?