{"id":312353,"date":"2010-02-12T10:14:58","date_gmt":"2010-02-12T15:14:58","guid":{"rendered":"tag:business.theatlantic.com,2010:\/\/3.35861"},"modified":"2010-02-12T11:48:35","modified_gmt":"2010-02-12T16:48:35","slug":"more-on-medicare-mortality","status":"publish","type":"post","link":"https:\/\/mereja.media\/index\/312353","title":{"rendered":"More on Medicare Mortality"},"content":{"rendered":"

You can expect that I’ll be blogging quite a bit about this topic over the next few days.  A reader in Tyler Cowen’s comments offers this 2009 study<\/a>:<\/p>\n

Health insurance characteristics shift at age 65 as most people become eligi-
\nble for Medicare. We measure the impacts of these changes on patients who are
\nadmitted to hospitals through emergency departments for conditions with similar
\nadmission rates on weekdays and weekends. The age pro\ufb01les of admissions and
\ncomorbidities for these patients are smooth at age 65, suggesting that the severity of illness is similar on either side of the Medicare threshold. In contrast, the
\nnumber of procedures performed in hospitals and total list charges exhibit small
\nbut statistically signi\ufb01cant discontinuities, implying that patients over 65 receive
\nmore services. We estimate a nearly 1-percentage-point drop in 7-day mortality
\nfor patients at age 65, equivalent to a 20% reduction in deaths for this severely ill
\npatient group. The mortality gap persists for at least 9 months after admission<\/p><\/blockquote>\n

I referred to three earlier studies, including one by Card, as
\nsurveyed by Levy and Meltzer<\/a>:<\/p>\n

Card et al. use a
\nregression discontinuity approach to estimate the impact of Medicare
\ncoverage on mortality.  The basic idea is that if health insurance
\nsignificantly affects mortality in the short run, the dramatic increase
\nin health insurance coverage at age 65 as a result of Medicare should
\ntranslate into a reduction in mortality at age 65 relative to the
\noverall trend by age.  In fact, the data show no such discontinuity: 
\nmortality changes smoothly with age.  Card et al. do find discrete,
\nsignificant increases in consumption of medical care.  They also noted
\nsome improvements in self-reported health at age 65, although many of
\nthese effects are imprecisely estimated.  One important exception is the
\n result for Hispanics and low-income minorities, both of whome see
\nsignificant increases in the probability of reporting good or better
\nhealth at age 65.<\/p>\n

Polsky et al. take a different approach to
\nestimating the impact of Medicare on health.  They analyze changes in
\nthe trajectory of self-reported health at age 65 adn find that receiving
\n Medicare increases the probability that respondents report excellent or
\n very good health.  One surprising aspect of these findings is that
\nthese shifts are observed both for respondents who were uninsured prior
\nto Medicare and for those who were otherwise insured.  This result is
\nsurprising because one would have expected benefits to be concentrated
\nin those who were not previously insured.  The observed improvements are
\n also surprising because Medicare often provides less comprehensive
\ncoverage than do most private insurance plans.  Polsky et al.
\nhypothesize that the effect may be due to the stability of Medicare
\ncoverage compared with private coverage.<\/p>\n

Finkelstein &
\nMcKnight use data from the 1960s to see whether geographic areas with
\nlower insurance coverage rates prior to the enactment of MEdicare
\nexperienced improvements in mortality following the enactment of
\nMedicare relative to areas with higher pre-1965 coverage rates.  Earlier
\n work by Finkelstein using this same strategy documents significant
\nincreases on hospital spending and utilization, but the work of
\nFinkelstein & McKnight finds no corresponding improvement in
\nmortality.  The authors conclude that in its first 10 years, the
\nestablishment of universal health insurance for the elderly had no
\ndiscernable impact on their mortality.”  Of course, this result applies
\nto Medicare circa 1970; advances in medical technology and in the scope
\nof Medicare benefits since then may have greatly increased the marginal
\nhealth benefits of Medicare coverage.<\/p>\n

Taken together, these three
\n studies of Medicare paint a surprisingly consistent picture:  Medicare
\nincreases consumption of medical care and may modestly improve self
\nreported health, but has no effect on mortality, at least in the short
\nrun.  Whether there are long-term effects remains an open question; this
\n uncertainty reflects the limited generalizeability of the natural
\nexperiment results.<\/p>\n<\/blockquote>\n

The science is always evolving. 
\n Obviously, if we get a lot of results showing that there is a big
\neffect at 65, I’ll change my mind; but right now, the bulk of the
\nevidence runs the other way.  It’s worth noting that the later Card
\npaper itself notes that the aggregate figures show no mortality
\nimprovement:<\/p>\n

As is true for health insurance more
\ngenerally (see Levy and
\nMeltzer [2004]), it has proven more dif\ufb01cult to identify the health
\nimpacts of Medicare.9 Most existing studies have focused on mor-
\ntality as an indicator of health.10 An early study by Lichtenberg
\n(2001) used Social Security Administration (SSA) life table data
\nto test for a trend-break in the age pro\ufb01le of mortality at age
\n65. Although Lichtenberg identi\ufb01ed a break, subsequent analysis
\nby Dow (2004) showed that this is an artifact of the interval-
\nsmoothing procedure used to construct the SSA life tables. Com-
\nparisons based on unsmoothed data show no evidence of a shift at
\nage 65 (Card, Dobkin, and Maestas 2004). Finkelstein and McK-
\nnight (2005) explore trends in state-speci\ufb01c mortality rates for
\npeople over 65 relative to those under 65, testing for a break
\naround 1966–the year Medicare was introduced. They also ex-
\namine the correlation between changes in relative mortality after
\n1966 and the fraction of elderly people in a region who were unin-
\nsured in 1963. Neither exercise suggests that the introduction of
\nMedicare reduced the relative mortality of people over 65, though
\nit should be noted that the power of these analyses is limited.<\/p><\/blockquote>\n

How
\n could mortality improve at the micro level, and not at the macro
\nlevel?  Increasing utilization of health services is not all mortality improving.  As I note in the column, health care can kill as well as
\nheal–one estimates puts the death from nosocomial (treatment-induced)
\ninfections at 80,000 a year. So while it’s entirely possible–indeed
\ncertain–that some number of people are saved by having insurance, it’s
\nalso very likely that some number of people are saved by not having it,
\nor having less generous insurance, because they don’t go in for a
\ntreatment that would have killed them.<\/p>\n

The 2009 paper was
\nlooking at a small subset of conditions that are urgent, and which we’re
\n relatively adept at treating.  But it may be washed out by the people
\nwho die having knee surgery.<\/p>\n

This is, of course, why comparative
\neffectiveness research is very popular among wonks.  But it’s trickier
\nthan it sounds, because patients are very heterogenous.  I actually
\nexpect this problem to go down in the next twenty years or so, as better
\n genomics gives us more of a handle on which treatments work for whom.<\/p>\n

One
\n thing it does suggest is that if we want to maximize the benefits from
\nexpanding insurance coverage, we really need to wage a scorched-earth
\nbattle against nosocomial infection.  Hospital hygeine has slipped
\nmassively from where it was in the thirties, because antibiotics have
\nmade health care workers lless urgent about it.  We need to return to
\nthe OCD days of yore.<\/p>\n



\n

\n Email this Article<\/a>
\n Add to digg<\/a>
\n Add to Reddit<\/a>
\n Add to Twitter<\/a>
\n Add to del.icio.us<\/a>
\n Add to StumbleUpon<\/a>
\n Add to Facebook<\/a>
\n

\n\"\"<\/a>
\n\"\"<\/p>\n","protected":false},"excerpt":{"rendered":"

You can expect that I’ll be blogging quite a bit about this topic over the next few days.  A reader in Tyler Cowen’s comments offers this 2009 study: Health insurance characteristics shift at age 65 as most people become eligi- ble for Medicare. We measure the impacts of these changes on patients who are admitted […]<\/p>\n","protected":false},"author":80,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[],"class_list":["post-312353","post","type-post","status-publish","format-standard","hentry","category-news"],"_links":{"self":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts\/312353","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/users\/80"}],"replies":[{"embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/comments?post=312353"}],"version-history":[{"count":0,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts\/312353\/revisions"}],"wp:attachment":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/media?parent=312353"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/categories?post=312353"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/tags?post=312353"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}