It’s a contentious question, but curiously, one that doesn’t get debated nearly as fiercely as things like “how many uninsured people are there?” I find that surprising, because after all, we don’t necessarily care whether people are marked by some survey as “insured” or “uninsured”; we care whether there is preventable suffering in the world.
But it turns out to be really hard to determine how many people die without insurance, which is the subject of this month’s column.
The most recent available study, which also had the largest sample and
controlled for the most variables, found no effect at all–a result
which surprised the hell out of its author, a former Clinton advisor.
Other studies say the number is in the tens of thousands.
The
left is predictably fond of the study which got the largest number,
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, with
parameters that somehow always conspire to produce the maximum possible
number. In the first study, they set an absurdly low threshhold for
what constituted a “medical bankruptcy”. In the second, they chose
2006, the year after the 2005 bankruptcy reform act had driven an
unprecedented spike in filings. It seems pretty likely that medical
bankruptcies were bound to be overrepresented in 2006, since most
financial events are easier to see coming than illnesses. But even if
you disagree–and the authors offered an incredibly wan explanation of
why they did–it’s very clear that the people who filed in 2006 were
not going to be a representative sample of bankruptcies in a normal
year. I can’t imagine why you would choose to study 2006 unless you
were looking for biased results. I have to conclude that their
political beliefs are affecting their work, which means I wouldn’t
touch that 45,000 number with a bargepole–I wouldn’t cite anything
they authored even if it offered to prove beyond a shadow of a doubt
that I was right about everything.
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”.
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. Probably the best one looked
at patients who had been taken to the ER, which still showed higher
mortality for the uninsured. But it’s not clear that this indicates
that lacking insurance is dangerous; it may be telling us that people
who lack insurance have a lot of factors that lead to poorer health
outcomes.
To my mind probably the single most solid piece of evidence is this:
turning 65–i.e., going on Medicare–doesn’t reduce your risk of
dying. If lack of insurance leads to death, then that should show up
as a discontinuity in the mortality rate around the age of 65. It
doesn’t. There are some caveats–if the effects are sufficiently long
term, then it’s hard to measure, because of course as elderly people
age, their mortality rate starts rising dramatically. But still, there
should be some kink in the curve, and in the best data we have, it just
isn’t there.
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. At minimum, I think we should
be pretty cautious about stating that we know how many people die from
lack of insurance. We don’t, and worse, we may never.
