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February 19, 2010

Does Health Insurance Save Lives? Maybe That’s the Wrong Question

Maggie Mahar
Do the uninsured die because they don’t have access to medical care—or because more than three-quarter of the uninsured are poor?  In part 1 of this post, I explained that we know that poverty is a killer. It destroys mind and body, slowly but surely. In the U.S. the poor die seven years earlier than the rich. And most of the uninsured are poor. 

I also explained that lack of access to medical care is not a major factor in determining who dies prematurely. Social circumstances, personal behaviors, and environment account for 60% of early deaths, and each is closely tied to socio-economic status.

Most Americans assume that good health care is the key to longevity. But in 2002 the Kaiser Family Foundation published a study that poses a radical question, “Does having health insurance improve your health?“ It might sound like a foolish query. One wants to say “Of course!”

But early in the report, the authors acknowledge that “there is no definitive research that unambiguously answers this question, one way or the other.”

Are We Over-Estimating the Importance of Medical Care on the Margin?

They explain why: “An ideal study designed to answer it would randomly assign a representative sample of people to insured (treatment) and uninsured (control) groups. People in the treatment group would presumably use more medical care than people in the control group because having insurance lowers the cost of care.

“The extra services used by the insured might be a mix of more preventive care, more screening and diagnostic care designed to detect disease at an early, more treatable phase, and more aggressive treatment of illness when it occurs. Some people without insurance would find such treatments unaffordable and choose to forego care. If these are the effects of having insurance, then we might very well expect the insured group to have better health after some period of time.

“But,” the report continues, “Suppose instead that the extra care received by the insured group was primarily medical services that were unneeded and provided little clinical benefit.  . . . Suppose also that people without insurance are generally able to get care when they really need it . . . .”

In other words, while the uninsured do not receive the chronic disease management that they need, when they become seriously ill, they wind up in an emergency room where, most of the time, they are rescued.

When researchers try to investigate the benefit of having insurance and easy access to medical care, they run into another complication:  if you look at the affect of additional medical care on healthy, well-insured peopled you find little or no benefit. For example, while the well-known RAND Health Insurance Experiment showed that low or no co-pays increases the amount of medical care people consume, “for the average person there were no substantial benefits from free care." 

However, as the authors of the Kaiser study point out, the problem of being uninsured is not, by and large, a problem for “the average American - it is primarily a problem for low-income people.” And precisely because low-income people are sicker than average, they need more medical care

The authors of the Kaiser report conclude: “Even if one accepts as valid the findings of the more methodologically sound studies that suggest little or no health benefit from additional medical care use by well-insured populations, it does not necessarily follow that the uninsured would not benefit both from health insurance coverage and from greater medical care use. Holding both points of view would not be inconsistent. In fact, it would seem to be both inappropriate and unfair to argue on the basis of these studies that the uninsured should be penalized, i.e., denied help in obtaining insurance coverage, because of the inefficient or excessive use of medical care by the well insured. 

“Even if the marginal benefit [of more care] to the average, relatively healthy, privately insured person is close to zero, it does not follow that the benefit is also zero for a poor patient.” 

The Uninsured Are More Likely to Die of Specific Diseases—But Why?

Studies of outcomes from specific diseases (breast cancer, colorectal cancer, cardiovascular disease, and trauma) reveal that the odds of dying within a particular time period were from about 1.2 to 2.1 times greater for an uninsured person with the particular condition compared to a privately insured person. We also know that the uninsured tend to be diagnosed later.

But they still can’t answer the question of causality:  Do tens of thousands of uninsured people die because they weren’t diagnosed in time? Or did they die because they were poor as well as uninsured—and thus not as strong as more affluent patients who managed to survive a heart attack or cancer? 

 In the end, studies linking the lack of insurance to mortality are inconclusive.  “These studies vary in how they report their results, some as relative odds, some as relative risk ratios, and others as elasticities,” the authors of the Kaiser study acknowledge. Taking these differences into account, their estimates of the quantitative effect of extending health insurance coverage to all suggest that “the mortality rates of the uninsured would decline by at least 5% and, depending on age and medical condition, by as much as 20-25%, with some studies suggesting that the reduction could be as high as 50%.”

In essence, they are saying that “while we are quite certain that access to care must benefit patients, we have absolutely no idea how large that benefit is.”                                      

The Wrong Question

Ultimately, when people ask “how many lives would be saved if we all had insurance?”  I think they are posing the wrong question.

A better question would be: “how many people suffer needlessly because they don’t have access to care?

Why should “mortalities” be the measure of how much good health insurance --or medicine itself-- can do? Health care will not rescue us from the human condition.  And as I explained in part 1, evidence shows that access to medical care is not the major factor that guards against premature death. Genes, social circumstances and personal behavior all are far more important.

Despite our national obsession with longevity, and our belief that hi-tech medicine will rescue us, the truth is that very often, modern medicine cannot cure us—but it can provide comfort and care.  This is why health insurance is important

Whether the patient is a child with an ear-ache, a 60-year-old who should have a knee replacement, or a chronically depressed 40-year-old, good insurance can provide access to the help they need. In a life-threatening situation, the uninsured may well get the emergency care that they need. But 21st century medicine can greatly enhance the quality of life; this is why everyone deserves access.

Richard Kronick agrees. In part 1 of this post, I explained that when he adjusts for demographic differences Kronick finds no evidence that an uninsured smoker dies sooner than a smoker who is insured. But he explained to Politifact.com, “he doesn't doubt that individuals' health suffers when they're uninsured.”  “No one would choose not to have insurance if they could afford it," Kronick added, "There's no benefit to having 47 million Americans uninsured."

Yet there is a limit to what insurance can do.  It cannot create jobs. Or safe playgrounds. Or urban farms on inner-city roofs. It cannot reduce class sizes in our public schools. It cannot build pre-schools.

If we are interested in reducing the level of premature deaths in this country, we must invest in public health. This means focusing on the poor.

As Schroeder pointed out in the 2007 Shattuck lecture: “To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health.  . .It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes.

Schroeder notes that few lobbyists represent the poor: “the disadvantaged are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties. Without a strong voice from Americans of low socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses, such as breast cancer, human immunodeficiency virus infection and the acquired immunodeficiency syndrome (HIV–AIDS), and autism. These efforts are led by middle-class advocates whose lives have been touched by the disease. There have been a few successful public advocacy campaigns on issues of population health — efforts to ban exposure to secondhand smoke or to curtail drunk driving — but such efforts are relatively uncommon. Because the biggest gains in population health will come from attention to the less well off, little is likely to change unless they have a political voice and use it to argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental threats.   . . .  In addition, the American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choices.”

Yes, without question, we need health care reform. But neither Aetna nor a single-payer system will save tens of thousands of lives. To do that, we need a war on poverty.  Schroeder suggests that in “the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for population health.. . . Americans take great pride in asserting that we are number one in terms of wealth, number of Nobel Prizes, and military strength. Why don't we try to become number one in health?”


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