• Our Unpublished Response to McArdle

    Unfortunately, the letter I drafted with colleagues in response to Megan McArdle’s March 2010 The Atlantic article “Myth Diagnosis” was not published in the magazine. Those that were did not make the same points we did (letters available online). Below is the text of our letter.

    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

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    • As I’ve said before to you and others, the most insidious part of this ongoing debate is the underlying assumption that the GOAL of health insurance is to have an impact on mortality. That’s why I really don’t like this statement:

      “Quite possibly, lack of health insurance has no more impact on your health than lack of flood insurance.”

      that implicitly equates “your health” and mortality, when most health care services are not really aimed at that at all, but at quality of life. Austin, since you’ve reviewed all this literature more than I have, has anyone attempted the (likely quite difficult) decomposition of quality of life effects from length of life effects. The ethical and societal dimensions of what I think the real debate should be about are huge. Let’s just take end of life care as an example (though in the US almost everyone at this stage has Medicare that covers the expensive inpatient care, so there is no basis for a study that I can immediately think of), where palliative care may improve quality of life but do nothing to extend life and may actually be correlated with mortality, and expensive ICU care may extend life but at a horrible quality of life cost. Insurance may actually pay for the latter better, of course.

      I continue to think the whole basis of this debate is muddleheaded, which allows opinions like McArdle’s to thrive. Anyway, I think you have heard this argument more or less the same from me already.

      Jim