Monday, October 26, 2009

The Health of America, Part 20

UPDATE: Berman Post picks up the point.

Congressman Alan Grayson (D.-Fla.) claims that "[e]very year, more than 44,000 Americans die simply because they have no health insurance." Single-payer insurance pressure groups and other lefties say the same. As does the mainstream media.

All such claims are based on a study called Health Insurance and Mortality in US Adults, published in the September 2008 American Journal of Public Health. In predicting that 120 Americans die daily because they lack health insurance, is the study valid? Like many claims about the uninsured, no.

Initially, though not definitive, I note that many of the study's authors are lefty single-payor advocates themselves, a fact the media mostly fails to mention. This doesn't settle the issue, but it does raise the question, as Michelle Malkin suggests, that the science might be "infused with left-wing politics." So, in assessing bias, consider the source.

More importantly, the study's methodology obviously is flawed. The paper uses survey data gathered between 1988 and 1994 by the National Center for Health Statistics (NCHS). About 34,000 people were interviewed about various health-related characteristics, including whether they were insured. The authors then excluded those over 64 (virtually of of whom are covered by medicare) and children under 17. They also excluded non-elderly already covered by Medicare, Medicaid or VA health insurance, because "a substantial proportion of those individuals had poor health status as a prerequisite for coverage." The researchers also culled those with missing or incomplete interview data. The resulting relevant population was 9,004 surveyed individuals, of which about 84 percent were listed as insured while the remaining 16 percent were not. In a 2000 follow-up of the 9,004 individuals, 351 (or 3.1 %) had died. Then, for the most part, they assumed that mortality among the uninsured was caused by the lack of health insurance. This is nonsense, for three reasons:

First, demographics matter:
People with insurance tend to be healthier, wealthier, wiser and more gainfully employed than people without insurance.

So you can't blame their longer lives only on their insurance.
To be sure, the study acknowledges several other factors contributing to mortality, such as "gender, age, race/ethnicity, poverty income ratio, education, unemployment, smoking, regular alcohol use, [sub-standard] self-rated health, [and sub-standard] physician-rated health." But, because they found "no significant interactions" between the lack of insurance and those other variables, the authors downplay those factors.

Second, there's scant causal connection. The lack of health insurance isn't static--over 80 percent of the uninsured regain coverage within two years. And one can't assume deaths were due to any lack of health care--after all, bad health care also can be fatal. Yet the study presumes lack of health insurance is among the causes. As John Goodman, president of the National Center for Policy Analysis notes:
The subjects were interviewed only once and the study tries to link their insurance status at that time to mortality a decade later. Yet over the period, the authors have no idea whether subjects were insured or uninsured, what kind of medical care they received, or even cause of death.
And the study itself concedes that "between 7% and 11% of those initially recorded as being uninsured were misclassified," raising questions about the sample's accuracy.

Third, other research is to the contrary. For example, a study by UCSD prof Richard Kronick, Ph.D., found:
Adjusted for demographic, health status, and health behavior characteristics, the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer-sponsored group insurance at baseline.
Further, a June 2009 report by Drs. June and David O’Neill of Baruch College found the differential mortality between insured and uninsured to be of questionable statistical significance, and in any event only about 3 percent when comparing the insured with the voluntarily uninsured. Overall, they conclude:
a lack of health insurance is not likely to be the major factor causing higher mortality rates among the uninsured. The uninsured--particularly the involuntarily uninsured--have multiple disadvantages that are associated with poor health.
Conclusion: I've always supported a tax-funded safety net for the poor, including for those who can't afford health insurance. But rejecting phony scare stories is crucial for assessing the scope of the actual problem and crafting the appropriate policy remedy.

Fables still generate more coverage than facts. Healthcare costs don't drive personal bankruptcies--consumer spending does. And while insurance coverage may have some relation to mortality, it's nowhere near the numbers claimed. So, consider carefully before abandoning a system that is comparatively good and cost-effective. Junk science is no reason to junk what works.


Anonymous said...

It's interesting that no one sees the 100% per cent correlation between breathing and death.

Anonymous said...

It seems clear that 44k is an overblown number. Care to hazard a guess at what the real number might be?

@nooil4pacifists said...

Anony: Give the left wing time. By the time the bill passes, with a bare majority, they'll say "even one additional death is too many."

Andrew: The O'Neill Study finds a three percent difference in mortality between insured and voluntarily uninsured, and that's probably a good number.

My view, and that of Dr Kronick, is that it is impossible to get a real number out of that NCHS database (which Kronick also used), because of self reporting bias, because the population was asked about insurance only once, and because they followed-up a decade or so later but only to find out whether the subjects were still alive, not whether they got insurance, changed doctors, had a auto accident, committed suicide, etc.

There was a previous study saying 18k annual additional deaths, which is bogus too.

And even if one hypothesized the creation of a new, huge population survey that asked the right questions and did so annually, the correlation between involuntary uninsurance, on the one hand, and dozens of other negative health indicia is so high that I think it almost impossible to separate the contribution of any given cause of increased mortality.

OBloodyHell said...

> It's interesting that no one sees the 100% per cent correlation between breathing and death.

Hey, mothers' milk leads, like, to heroin, man...

Really, man. Many of those on heroin once partook of Mother's milk.

The truth is out, there... man.


@nooil4pacifists said...

I'm actually surprised that so little attention has been paid to this obviously bad study. The truth may be out there -- OBH and Anony are right that the logic is lacking -- but damn few notice.

Anonymous said...