• Consequences of Uninsurance

    Apparently Megan McArdle is not convinced that health insurance promotes health. I assume she (and any reasonable minded individual) would agree that death can be caused by lack of sufficiently good health. It is, therefore, only a trivial bit of logic to conclude that if insurance promotes health it can also be life preserving. Or, turning it around, if uninsurance leads to bad health outcomes it can also increase mortality.

    That uninsurance is bad for you is easy to defend if you know the research. There is a large body of health services and health economics literature that documents the negative effects on health due to lack of insurance. My own work with Steve Pizer and Lisa Iezzoni, published in Health Affairs, reviews some of that literature as it pertains to individuals with chronic health conditions.

    Using data from the National Health Interview Survey, a recent report found that 46.0 million nonelderly U.S. adults (ages 18–64) reported having at least one of seven major chronic conditions in 1997; by 2006, that number had risen to 57.7 million.[1] This and other studies document much lower access to care among uninsured people with chronic conditions compared with insured people. Adverse access markers include lower rates of having a usual source of care, fewer primary care and specialist visits, more frequent use of emergency departments (EDs) for primary care, and difficulties affording services.[2] Such studies complement a growing body of research documenting poorer health outcomes among uninsured people with chronic conditions. [3-6] Acquiring health insurance can improve people’s health and change downward trajectories of functional declines.[7]

    (Bold mine.) Since health outcomes pertaining to the transition to Medicare is one focus of Megan McArdle’s Atlantic Monthly piece (see also her related blog post; h/t Tyler Cowen), let’s focus on that for a moment. In Health of Previously Uninsured Adults after Acquiring Medicare Coverage [7] McWilliams, et al. find that

    eligibility for Medicare coverage at age 65 years was associated with significant improvements in self reported health trends for previously uninsured adults relative to previously insured adults. … our findings suggest long-term benefits of gaining insurance on the health of previously uninsured Medicare beneficiaries, particularly those with cardiovascular disease or diabetes.

    (Again, bold mine.) The evidence that insurance and the access to care it facilitates improves health, particularly for vulnerable populations (due to age or chronic illness, or both) is as close to an incontrovertible truth as one can find in social science.


    [1] Hoffman C, Schwartz K. Eroding access among nonelderly U.S. adults with chronic conditions: ten years of change. Health Aff (Millwood). 2008;27(5):w340–8.

    [2] Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med. 2008;149(3):170–6.

    [3] Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. New Engl JMed. 1993;329(5):326–31.

    [4] McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Health insurance coverage and mortality among the near-elderly. Health Aff (Millwood). 2004;23(4):223–33.

    [5] Ayanian JZ, Zaslavsky AM,Weissman JS, Schneider EC, Ginsburg JA. Undiagnosed hypertension and hypercholesterolemia among uninsured and insured adults in the third National Health and Nutrition Examination Survey. Am J Public Health. 2003;93(12):2051–4.

    [6] Fowler-Brown A, Corbie-Smith G, Garrett J, Lurie N. Risk of cardiovascular events and death—does insurance matter? J Gen InternMed. 2007;22(4):502–7.

    [7] McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298(24):2886–94.

    • McCardle’s not talking about health, she’s talking about mortality. You point to studies that find a correlation between health status and insurance coverage, and say that it’s but a trivial bit of logic to go the next step. But of course what’s needed is logic, it’s evidence. And McCardle grapples with the evidence on mortality, and you don’t.

    • Actually, Austin does research, considers relevant evidence, and lists a large bibiliography at the end. McMegan finds evidence that contradicts her preference for letting the poor live miserable lives and die early, picks away at some minor and entirely predictable quality of data issues, and pronounces herself convinced that nothing should happen to prevent poor people from living miserable lives and dying early.

      Of course, you might be more open to drawing your conclusions from the available evidence. Therefore, in addition to Mr. Frakt’s useful post, I suggest you also try Mr. Klein’s post: http://voices.washingtonpost.com/ezra-klein/2010/02/will_health-care_insurance_sav.html#more.

    • Everybody dies, and insurance doesn’t prevent it.

      It’s called health insurance, not death insurance. So it’s not surprising that Megan is having a hard time with the mortality numbers.

      If insurance isn’t affecting mortality rates, why do people buy it? Because people want more than just a non-corpse status. Doh!

      • @paul o (and everybody) – Don’t believe it when Megan says insurance doesn’t affect mortality. That is not a correct read of the literature. Stay tuned. I’ll have it here by the end of the weekend (Monday is a holiday).

    • Thanks for rounding this up. Megan is missing the point, which she does a lot on this issue. I like her work and admire a lot about it, but I really don’t think she understands the stakes here. The cool contrarian tone of all of her healthcare posts suggests that she’s someone with a radically different understanding of this issue from me. Having a system that leaves substantial portions of the population without access is pretty horrific if you ask me.

    • Given Robin Hanson’s work, the reasonable conclusion isn’t that more medicine has no effect on anyone, it’s that more medicine has a positive effect on some people and a negative effect on others, leaving it roughly a wash overall. Thus, there’s no inconsistency between your claim that insurance helps people with a few specific well-understood chronic conditions and Megan’s claim that you can’t see much benefit in the overall stats – it just means that people who *don’t* have those few specific well-understood conditions are on net harmed by getting insurance.


    • I have been surprised by the willingness of many to accept the argument that having access to health care makes one healthier.

      If that were true we would have seen numerous studies providing comparisons of the relative health of those using health care and those who for religious reasons do not – Christian Scientists are certainly a large enough sample to provide the proof to the health care makes people healthier argument.

      If such a study exists I have yet to see it referenced.

      • @Lonely Libertarian – I don’t know why your measure of proof requires a study of Christian Scientists. There are plenty of other studies, enough that a reasonable person ought to be convinced. For a summary, read this blog tomorrow.

    • Austin,

      I look forward to reading what you have to share tomorrow. My problem with many of the studies that some find convincing is that they rely on samples that are flawed. For example – I will agree that folks who are unemployed are less healthy than the employed – but that does not convince me the CAUSE of their relatively poor health is lack of insurance when it might very well be that they are less healthy due to a lack of a job.

      My only point in asking if someone had done a scientific study of those who choose not to engage in traditional health care – the Christian Scientists are only one possibility – was that this might be a way of controlling for things like employment, social status, income, etc…

      • @Lonely Libertarian and Glen Raphael – Perhaps a study of Christian Scientists would be revealing. But I would not wait for such a study to draw a conclusion about the effects of insurance on health outcomes. The existing literature is quite convincing. Keep in mind it isn’t perfect. This isn’t physics. If one wants to cherry pick studies and take a very narrow view about what is acceptable evidence one can form a different opinion. Nobody can convince everyone of anything in social science. But the burden of proof that lack of insurance has no effect on mortality is on the deniers. The very notion runs counter to every reasonable conceptual model of medicine and health care and a vast amount of empirical results.

        The post tomorrow that reviews the literature (or the subset of it that fits in a blog-length piece) is not by me, but is a guest post by someone who knows that literature far better. The post will also reference a lengthier review so one can find more on this if one wishes (I’ve already cited it in my posts actually). I am not at liberty to make sure the review satisfies any particular request for content. It will be what it will be, but it should be quite a sufficient review and far more thorough than McArdle’s.

    • Christian Scientists do seem like an excellent test case. At the time that church was founded, church members were almost certainly healthier than the general populace due to (a) Mary Baker Eddy’s emphasis on cleanliness – especially frequent hand washing at a time when that was rare, and (b) medicine then was terrible. The question is whether that’s still true today.

      When you collect your studies for tomorrow, what we really want is a demonstration that if you ran the Rand Experiment again today you wouldn’t get the same result – that people who paid for their own care used half as much but were roughly as healthy as those who got “free” care. We want to see svidence that more heath care results in better health *outcomes* – not just input measurements like blood pressure but mortality or quality-of-life – and that it does so in a general population – not just a population suffering from a specific problem – and does so to a degree that isn’t explainable as the result of selection bias or placebo effect.

      The conventional wisdom is based on medical studies. There are vast numbers of medical studies showing that in a population with exactly one specific carefully-diagnosed condition and no confounding other conditions, an expert spefcialist who is competently following a specific protocol will produce better results than one following some other protocol. Sometimes there’s even a “control” group. There is a huge selection bias effect in that studies that didn’t find the treatment to work usually don’t get published, but even when the study finding is reliable, it’s not clear how well it extends to less-competent doctors treating patients who have multiple problems and might have been misdiagnosed. The long-term results of following a “do nothing” option often isn’t considered ethical so Christian Scientists might be one of the few populations where you could find cases where that option is seriously practiced.

    • Austin,

      I look forward to reading tomorrows post – and I have TRIED to stay open minded on this issue – but I get a bit nervous when people suggest that the burden in on us skeptics [and use loaded terms like deniers to describe me].

      What is being proposed is a system that would FORCE people to initially get insurance and taken to a logical conclusion FORCE people to get health care.

      I would argue that there is at least some minimal obligation on the part of “true believers” to show that I will not be harmed by being forced into this sort of system.

      Another question that I cannot get answered is where will the supply come from to meet the increased demand for health care services – and how are we going to know that the added supply of health care is of the same [or better] quality as the existing supply.

      If some of my doctor friends are to be believed we face the possibility that supply might of quality health care might actually decline.

      I see the two questions related – if we want more health care and believe that it is a good thing then we have to find ways to expand the supply of quality health care – or am I missing something…

      And great post Glen R.!

      • @Lonely Libertarian – Let’s separate two things. One is the question whether the empirical evidence demonstrates that insurance leads to better health outcomes and decreased mortality. The second is what may happen in the market as a result of proposed reforms. The two are related, of course. But the answer to the first is, I assert, clear. Those who doubt the positive effects on health of insurance have the burden of proof on that one.

        As to how reforms will affect individuals and the market, I think the burden of proof is on proponents of reform. But recognize that’s not an empirical question. It can be informed by evidence but it requires projection into the future. However, an honest view also examines the projection of the status quo.

    • Well now I am confused….

      Is it INSURANCE that causes better health and lower mortality or HEALTH CARE. Because I don’t need the one [insurance] to have the other [health care] – and having the one [insurance] may not lead to the other [health care].

      For those with annual incomes over around $150,000 there is a pretty good argument for self insuring up to say $10,000 a year [my doctor discounted my bill 50% when I paid cash]

      Catastrophic coverage for the big C and other extraordinary events would seem to make sense for 90% or so of that group…

      I really do wish the answer to “the first part” was as clear as you feel it is…

      • @Lonely Libertarian – You are entitled to as much confusion as you wish. Of course it is the care, not the insurance, that matters. Otherwise we’d cut out the doctors and save a lot of money.

        In principal health care doesn’t require insurance. In practice lack of insurance poses significant barriers to access and affordability of care. Please do try to keep the issues straight. There are empirical findings (see lit tomorrow’s post) and there is what you want the world to be like. Those are different things.