• Health insurance is good for health

    Is this really controversial? Evidently, some of you think it is. I was reading a Viewpoint in JAMA when I stumbled across this (emphasis mine):

    For years, clinicians have advocated for health insurance coverage for all Americans. Now, through the Affordable Care Act, the nation is one step closer to this goal. October 1, 2013, marks the beginning of a new era when millions will be able to enroll in health insurance at the Health Insurance Marketplace. Ushering in this new era presents an enormous opportunity for the entire health care system. It has never been more important for physicians and other health care professionals to be engaged in connecting people to coverage.

    As a physician and nurse, respectively, we have too often witnessed how the lack of health insurance can negatively affect a patient’s health. According to the Institute of Medicine, coverage is essential to health and wellness. Uninsured adults are more likely than insured adults to be diagnosed at advanced stages of cancer or die of stroke or myocardial infarction. They are also less likely to have a usual source of medical care, decreasing their likelihood of receiving preventive and primary care.

    The piece itself won’t hold much new information for those who regularly read the blog. But I was struck by the fact that the Institute of Medicine has pretty much confirmed what used to be a widespread belief – that health coverage is linked to health. It’s strange to me that I’ve spent the last week arguing with people who feel otherwise.

    I’d also take more people making that argument seriously if they, themselves, were giving up their health insurance.

    @aaronecarroll

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    • This is only an anecdote, but it supports Dr. Carroll. About 18-19 years ago, my sister was diagnosed with cervical cancer. She resided in the low country of South Carolina. I had a fishing buddy (we resided in different regions) who was an oncologist who had studied at Duke, and I called him for a referral for my sister. To my surprise, he told me that the nation’s leading oncologist specializing in cervical cancer was located in the low country. Why, I asked, was he in the low country. Because that’s where the patients are: the low country had the nation’s highest incidence of cervical cancer. I assumed it related to all the chemical plants in the region (for those who aren’t familiar, chemical plants are ubiquitous). That was one theory, but according to my friend, the reason was that there are so many poor people in the region without insurance who receive inadequate care, certainly not preventive care like regular exams and pap smears, and who don’t seek care until the symptoms of disease force them to.

    • Ok the last crack by Aaron is unfair to folks like McArdle, etc. since that line of argument is pretty weak. Its similar to the whole “why dont you just send a check to the government if you favor higher taxes and more public services” argument and neglects the reality of collective action issues or regulatory arbitrage. In McArdle’s case, its probably the latter as she receives subsidised insurance.

      Anyway, there is quite a literature out there that disproves McArdle & minions so it wouldnt be hard to find more than a JAMA article. If you go to her blog, the papers she cites are pretty weak (much weaker than Oregon btw)…

      • There is a WORLD of difference between people who say that Medicaid needs to be reformed versus those who think it needs to be completely denied. Moreover, there are people out there who absolutely argue that health insurance does not improve health. Full stop. Almost none of those people have dropped their plans.

        • Thank you.

          I’d like to see some of those people have some health problems & try to get them taken care of with limited funds & no insurance for a few years.
          Seriously… I’ve come to that point, I actually wish it on those people, and I feel less & less guilty by the day about wishing it… because I feel like it has to get that bad, and some people really need consequences that serious, to get a clue & stop being complete jerks about the matter. People’s lives are depending on them waking up & start facing the truth.

          • Unfortunately when empathy and humanitarianism are missing, the only way the system is changed to address serious problems is when those who make decisions directly suffer the consequences of those problems.

    • Hi,

      Here’s one reason the association between health insurance and health might be controversial: If people have had economics training and learned about moral hazard, they might think having no health insurance is related to healthy behavior. Specifically, “ex ante moral hazard” means that people are less careful with their health when they are insured; being sick means you get free care so there’s no reason to be careful. Conversely, when you’re not insured, you’re likely to be careful and highly motivated to stay healthy; being sick means paying medical bills and you want to avoid that.
      I wrote a paper on moral hazard and it has a section about ex ante moral hazard (p. 23) if you’re interested: http://arno.uvt.nl/show.cgi?fid=129317
      Spoiler alert: there’s barely any evidence that health insurance induces more risky / less careful health behavior.

      Job

    • I view health insurance primarily as a way of insuring that I’m not bankrupted by a medical catastrophe, as opposed to a way to improve my health. My insurance doesn’t cover preventative care, which means my physicals come out of my pocket (it’s cheaper than having insurance cover it).

      I will admit that given the unfairness of billing the uninsured, you now need health insurance to cover a minor problem like a fracture.

      However, I am skeptical that insurance improves my medical health (as opposed to my financial health, where it significantly reduces risk).

      I view money as the reason the poor skimp on needed medical care and insurance is a way of fixing that. However, in general, they need subsidized insurance, which comes back to money as the problem.

      In short, I’m not convinced that health insurance improves health and I have no intention of giving mine up.

    • Although I applaud the authors of the NEJM paper for assembling all of this data, the bottom line, and what really should matter is an overall survival analysis presented as a Kaplan–Meier curve for the two groups. Two years is a short period of time, but ultimately, a statistically significant increased probability of survival is what matters. This could be assess by gathering death records for the two groups, which would probably be easier than gathering their clinical data.

    • Why is there so little discussion of cost-benefit?

      I have seen four basic arguments in the last week:
      1. Increased Medicaid coverage will help bend the cost curve
      2. Increased Medicaid coverage improves health
      3. Increased Medicaid coverage increases overall cost
      4. Increased Medicaid coverage does not improve health

      1 & 4 are the partisan throwaway positions. 2 & 3 are where the interesting discussion should be. Many people (including a surprising number of health care administrators) think that increasing quality (or improving outcomes) will reduce cost.

      The discussion really should be: expanding Medicaid looks like it will increase US healthcare costs, but the improved health may be worth it. It is rare that it is framed this way, so we end up with partisans talking past each other.

    • The idea that Health insurance is not good for health is interesting because it is so counter to what one would think. What seems to be true is that it has health insurance is far less good for health than most people think, so that brings in ideas like: If all the people who drive old cars put there health insurance premiums into a new car payment would there their average health be improved.

      • BTW: I support Medicaid (really not Medicaid as it is but something like it but more rational that sensible provides care for the needy). What does not make much sense to me in medicare and the Government’s demonstrated inability to hold costs down to what I think it could. Aaron has shown that Medicare holds down cost better than private insurance and I can accept that but still think Medicare for various reasons (being so big and having Government control of so much like licensing) should be able to hold down costs far more that it does. And why do we subside the least effective care, that is care for people above 65, for people with above average wealth/income? And why do we have this pretend system where it appears to have its only special tax?

      • But really… do you have health insurance so you will be healthier? Or do you have it so that if you need health care, the cost is muted?

        I’m seriously asking. I don’t think most people think of health insurance as a quality thing. It’s an access thing.

        • ” I don’t think most people think of health insurance as a quality thing. It’s an access thing.”

          Because it’s not a quality thing. It is a money making thing. More people are realizing that the system is a cartel.

          As SAO said, health insurance is a means to avoid bankruptcy ( among those who have assets to lose).

          Now with the mandate, it is trying to avoid a small tax penalty and trying to avoid bankruptcy.

          Will the first reason be enough to push healthy people without significant assets into the hands of insurers, only time will tell. The second reason isn’t really addressed. It only pads the insurers profits ( and wrongly convinces physicians that they will have more paying customers) .

          If coverage doesn’t materialize, the options on the table are:

          1. Exclude medical expenses from bankruptcy, like student loans

          2. Significantly raise the penalty and add provisions for criminal prosecution.

          3. Refuse care to uninsured patients

          I do not advocate any of these options, however I do expect the Gruberesque to justify this in the name of the system.

          I would rather see :

          1. Ending state licensure requirements for providers. If Obamacare is constitutional, surely this is under interstate commerce.

          2. Allowing practicing providers from other countries to practice in the U.S. without the egregious requirement to redo residency (indentured servitude) .

          3. Significantly reduce control of most pharmaceuticals.

          If Healthcare quality is not the major concern, multiple markets will develop, of varying quality. However the cost of the markets will decrease, become affordable for each market tier, and end the healthcare monopolies and rentier activity that exists today.

        • Being a small business owner I have the option to forgo health insurance or to get a low deductible policy but I have a health insurance policy with a $10,000 per person per year deductible for my family (I would have gotten a higher deductible if I could have found one, too late now my wife has existing conditions). I have it as you say only to mute costs and because the insurance company negotiates prices for me. I do not expect it to be healthier than I would be without it but It is often argued that people need to be forced to buy low deductible health insurance because if they do not have health insurance they will be less healthy. More precisely people will say if some people do not have health insurance they will delay treatment and so the cost to treat will be much higher. They might say, they will not treat their high blood pressure and that will lead to an expensive stroke or heart attack. They might say that some will not treat high blood sugar and that will lead to a costly amputation. To me these are a arguments that health insurance improves health.

          BTW I am annoyed when the pharmacist or my doctors tells me that the insurance company is paying part of my bill even though I have not reached the deductible. I would rather have a lower premium and pay directly for more.

    • “I’d also take more people making that argument seriously if they, themselves, were giving up their health insurance.”

      This is a non sequitur. I may believe that increased access to health insurance doesn’t improve actual health very much if at all (because many people access healthcare in actual emergencies regardless of their health insurance status, and because much of what we do in healthcare isn’t that helpful anyway and often is positively harmful, e.g., someone who catches MRSA at a hospital thanks to poor hygienic practices by the nurse).

      Nonetheless, I want to keep my health insurance because I want to avoid financial risk.

      That’s not hypocrisy in any sense whatsoever. It makes absolutely no sense to say that my views on how health insurance directly impacts health are somehow undermined by my desire for financial security.

    • Since our family went without health insurance from 1998 to 2008 I doubt there is much you can say that will convince me that health insurance is “essential” to good health care. From 1983 to 1998 we were a healthy family with a minimal health claim record and did not have any unhealthy habits. Since we were the perfect health insurance customer, I opted to assume the risk and save some money by self insuring. Our “wellness plan” was to continue doing the same things that worked for us over the previous 15 years and not think about health insurance. It worked. In 2008 I took a new job and started purchased health insurance using a HRA. Once again health insurance was a non-event. Our job was to continue to do what worked for us over the previous 25 years. So in 2013 we have been a healthy family for thirty years regardless of whether we were covered by health insurance or not. Obviously health, wellness, and insurance coverage works sometimes for unhealthy people but the word “essential” is too strong for healthy people like me with thirty year track records to back it up.

      When I was treasurer for a local Habitat for Humanity affiliate I knew two female homeowners who died from cancer. Both women qualified for Medicaid but they did not sign up. There were free health clinics in the neighborhood and a major hospital only ten minutes away. They did not use either of them. We did not find out about their illnesses until we knocked on the door and asked them why they were behind with the mortgage payments. Getting low income people to embrace health, wellness, and the benefits of health insurance coverage is a cultural problem that will not be solved by expanding Medicaid or handing out health care subsidies.

      • Any suggestions on how to address the cultural problem? Living in a system that forces (“medically necessary services” cannot be offered outside the single payer provincial systems) equal health care for the 1% as for the 99%, Canadian Medicaid for All still produces unequal results. From last summer,

        “The gap in self-reported health status between income groups seems to be growing, with 39 per cent of those whose households earned less than $30,000 a year describing their health as excellent or very good compared with 68 per cent of those earning $60,000 or more.”

        It’s not barriers to access causing the difference: “People in the lowest income bracket also reported accessing health-care services more often in the past month, 59 per cent, compared with 43 per cent among those earning the most income.” http://www.cbc.ca/news/health/story/2012/08/10/health-income-cma.html

        Income related issues seem to be healthy eating and exercise.

    • This is a sad and maybe not-innocuous trend you see in all sorts of edited periodical literature I think, this desire not to alienate any readers or take anything that could be perceived as a moral stand. Cf the New York Times’ refusal to call waterboarding “torture.”

    • “I’d also take more people making that argument seriously if they, themselves, were giving up their health insurance.”

      The primary reason I carry insurance is to protect my assets. If I was young and had no assets and the cost of insurance was preventing me from developing those assets I would can the insurance.

      I would, however, consider carrying very high deductible insurance that would provide for unexpected needs that I could not otherwise afford. That means high deductible similar to what people pay for homes, cars etc. all on credit.

      The only time I would use low deductible insurance is for convenience or because I am compelled to use it. The cost of first dollar care or near first dollar care is extraordinarily expensive and in my opinion a waste of valuable resources.

    • It is oversimplifying the issues to say that health insurance leads to better health. It may lead to additional medical services for some people, which may or may not contribute to their health.

      There is a confounding factor: the majority of the uninsured live in or near poverty, which is its own health hazard. Medicaid members still die younger than their peers who have private health insurance. Yet both have health insurance. Social-economic status is the largest determinant of health, no matter whether the person has health insurance.