Saturday, November 22, 2008
18,000 Deaths From Lack of Insurance?
Another Misleading Factoid from the Institute of Medicine
By Greg Scandlen
Filed As: Health Care
Like other misleading claims, this one is also based on a report by the Institute of Medicine. It is based on a series of reports paid for by the Robert Wood Johnson Foundation (RWJ) and issued by IOM as part of its “Coverage Matters” series. This one is called “Care Without Coverage: Too Little, Too Late.”
The study conducts no original research, but is a “meta-analysis” of existing studies. There is little consistency between these studies in quality or methods, and all are “observational rather than experimental,” as the IOM report acknowledges. The Urban Institute’s Jack Hadley conducted a similar meta-analysis at about the same time [Jack Hadley, “Sicker and Poorer: The Consequence of Being Uninsured,” Kaiser Commission on Medicaid and the Uninsured, May 2002] and was candid. He wrote, “Observational studies by themselves cannot answer the question of whether health insurance directly affects health outcomes because they cannot identify the causal direction of the relationship between insurance and health and may not be able to control for other, often unobserved, factors that might be affecting insurance coverage and health at the same time.” In other words, there may be some other condition that leads people to be both uninsured and in poor health.
Very few of these underlying studies adjusted for socio-economic differences in the populations, which is a major problem since income and education are closely associated with health outcomes regardless of the kind of insurance coverage involved. [See NCPA BA #415] We know, for instance, that people on Medicare all have the same insurance coverage, but 54% of those under the poverty level report themselves as being in poor or fair health, as compared to only 25% of those above 200% of poverty. The “universal” systems in Canada, the United Kingdom, New Zealand, and Australia report even bigger income-based disparities with lower-income adults over three times as likely as higher-income adults reporting themselves to be in “fair or poor health.”
While IOM did not correct for income differences in the populations (insured vs. uninsured), it had available a proxy for income. Many of the studies it looked at did separate out the Medicaid population from the uninsured and the privately insured populations. Lacking other income information, IOM might have studied people on Medicaid as being both low-income and fully-insured. But this result did not suit its predisposition, so it chose to downplay it. Deep in the report it acknowledges that, “study results for overall health status, cancer outcomes, and hospital-based care, (find that) adults with Medicaid frequently fare no better and sometimes far worse than uninsured patients in their health-related outcomes….” One might conclude that it is better to be uninsured than to be fully-insured on Medicaid. But IOM says such a conclusion would be “facile.” Why? Because Medicaid is a lousy insurance program that doesn’t pay doctors enough. Ah! But that still doesn’t explain why, if having insurance is the most important factor in health, people with no insurance fare better than people with poor insurance.
In fact, the evidence strongly suggests that insurance is not the most important factor in health – income and education are. But RWJ wasn’t paying IOM to come to that conclusion.
BOX
This author reviewed all of the 139 studies that comprised IOM’s analysis and found that only seven of them adjusted for income, but 44 identified the results of Medicaid enrollees separately from the uninsured and 26 compared the uninsured only to people with private insurance, omitting the role of Medicaid and Medicare. In 31 of the 44 studies that separated out the Medicaid experience, people on Medicaid did worse than the uninsured on a range of health treatments and outcomes. In a few cases, the uninsured and Medicaid patients both did better than the privately insured, such as mortality in the hospital.
What about the 18,000 deaths? The number shows up only once in the entire report, buried way back in Appendix D that explains the tortured methodology used to come up with that number. First, they rely entirely on a single study that estimated “a higher overall mortality risk for uninsured adults of 25 percent.” Linda Gorman deconstructs this original study persuasively. She notes the study by Peter Franks begins by looking at people who were uninsured or privately insured in 1971 and then looks at their mortality in 1987. Never mind that this entire population likely went through many spells of being covered or not being covered in the intervening years.
IOM then assumes that the incidence of diseases like diabetes, hypertension, breast cancer, and HIV are the same in the uninsured population as they are in the privately insured population. So they multiply the death rate for the insured by 125% and get the “excess mortality” of the uninsured. Voila! 18,000 dead.
There are at least two problems with this approach. First, the uninsured are not a monolithic population. They include people who are between jobs, people who are eligible for Medicaid but not yet enrolled, the young-invincibles who don’t think health insurance is valuable to them, some pretty wealthy people, some pretty poor people, and a lot in between. It also includes a large number of Latino immigrants who are newly arrived in the United States and who are pretty healthy. There is very little that unifies the uninsured, and certainly not their rate of mortality.
Second, the assumption that the uninsured have the same incidence of disease is almost certainly not true for two reasons: 1. The uninsured are considerably younger than the general population, and 2. People with high risk factors are far more likely to stay insured once they have coverage. They will stay with their employer, exercise COBRA options, pay more to get and retain coverage, enter high-risk pools, and pretty much make having coverage a major priority in their lives, because they know they need it.
So, once again, of all the things that might be said about the uninsured, the one thing that is almost certainly not true is that 18,000 of them die each year simply because they do not have coverage
- posted by Greg Scandlen
- 10:18 am
- 0 comment
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