Matthew Yglesias twitters “Do rightwingers really believe that US health insurance has no mortality-curbing impact?” Austin Frakt suggests that I am somehow in the grip of this ridiculous belief, and goes onto say that the state of knowledge is beyond the point where we need to understand the size of the effect.
I question the description of myself and Tyler Cowen as “rightwingers”–conservatives hate a good third of my positions at least.
But to answer the
question anyway, I thought I’d made it clear, but apparently not: I
think it is possible that the lack of insurance has no effect on
aggregate mortality statistics. I do not think that this is likely, but
I think it’s possible. What I think is likely is that the effect is
not that large, because if it were large, it would be very surprising to
see so little effect on the mortality of an elderly population with a
high mortality rate, or to have a study that samples 600,000 people and
finds no effect.
Mostly what I think is that the statistics are
really, really flawed. Not because the authors are bad social
scientists, but because this stuff is so hard to tease out. Natural
experiments are rare, and data sets often hard to come by.
This
is about how I feel about the minimum wage. My intuition is that demand
curves slope downward, so if you raise the price of labor, employers
are likely to consume less of it. But if you can get a study like Card
and Krueger, than the effect simply can’t be that large–at least,
within the range that the US usually plays with the minimum wage. I
don’t think it’s particularly good public policy, because too much of it
goes to middle class teenagers and the like, and even small
disemployment effects are dangerous for vulnerable populations. But I
don’t think it’s super-terrible public policy either.
I’m much
more convinced by the benefits of health insurance for certain
subpopulations, particularly people with diseases we’re very good at
treating. HIV seems to pretty convincingly respond to offering public
treatment–which also has a pretty compelling public health rationale.
(I don’t want to hear anything about spears
mounted on steering wheels, thank you very much). Medicaid
expansions provide some pretty good natural experiments, IMHO,
indicating that you can improve infant mortality. Poor people with
hypertension get better blood pressure control pretty consistently.
But
this doesn’t imply a large effect in the macro data if we extended
health coverage, precisely because not that many people under the age of
65 die of things we can treat. That whole age group is only about a
quarter of deaths, and some of them are from things like metastatic
cancer or auto deaths, in which more health care coverage can at best
eke out moderate further improvements. (That may not be true in the
future. It is now, sadly.)
Obviously, this matters. If 45,000
people die a year, this makes a more urgent case for overlooking the
drawbacks of single payer than if 1,000 people die a year–there are
probably more cost-effective ways to control those deaths.
But
that is far from the whole calculation. The mortality question is
really important, but it doesn’t touch non-mortality outcomes, which are
even harder to measure comprehensively. It doesn’t touch on the
financial questions raised by medical bankruptcies–I think they’re
overstated by the Himmelstein/Woolhandler crowd, but that doesn’t mean I
think they don’t exist. It doesn’t address the social justice
questions. It just says, this is probably not the best grounds upon
which to make the case for national health care, because we don’t have a
good handle on the number.
What it might do is point us towards
the shape of expansions. To the extent that the data make a strong
case, it might point to more modest interventions: prenatal and infant
care. Tuberculosis and HIV. Certain kinds of chronic conditions
(hypertension is really relatively cheap to treat, and very important,
although as with diabetes compliance is apparently a giant problem even
when there aren’t cost barriers). I’d probably support most of these.
But
the core question for me is not whether there’s any effect–I’m willing
to consider the possibility there isn’t, but I tend to assume there
is. The question is, how big? Because if it exists, but it’s too small
to measure, it might not be the issue our government should be most
focused on. Particularly when you consider that there are costs, as
well as benefits, to a national health care system.
