Does losing health insurance make you more likely to die? Several years ago, while I was writing my book on health care, I spent a lot of time on that question. I read the two highly publicized reports by the Institute of Medicine (IOM): Care Without Coverage: Too Little, Too Late and Consequences of Unnsurance. I read through the underlying research. And I spoke to as many experts as I could find.
The IOM had concluded that lack of health insurance led to 18,000 deaths a year--a figure that, some experts suggested, was a bit arbitrary. Isolating the effects of uninsurance was just too difficult to arrive at such a specific number. But, plainly, lack of health insurance left people in worse health. Many of them, most likely in the thousands, died every year. The cause-and-effect was certainly consistent with my own observations as a reporter, some of which I'd written about over the years. And so while I didn't make a habit of citing the 18,000 figure, I would (and still do) frequently cite the IOM report, explaining that "thousands" of people die every year because they can't get afford to get recommended medical care.
As you may have heard by now, Megan McArdle has written an article for the Atlantic Monthly questioning that assumption. She's not foreclosing the possibility that uninsurance might make people more likely to die, but she thinks the data hardly support that conclusion. It's not the first time she, or other critics of health care reform, have raised questions about the relationship between health insurance and health outcomes. Since that article's publication, I've been hoping to do what I did a few years ago--sit down with her article, the underlying data, and the compare those with the latest studies on the subject. But I've been too preoccupied with other assignments and tasks.
Ezra Klein, fortunately, has done the due diligence, publishing not one but two lengthy responses to McArdle. He's also posted a guest blog item from the Urban Institute's Stan Dorn, who was the lead researcher on that original IOM study. Austin Frakt has weighed in on this; so has J. Michael McWilliams (guest-posting on Frakt's blog). All of them think McArdle is simply wrong, on the merits. My reading is that they have the better of this argument, by far. But you should read the items, including the rejoinders McArdle posted on her blog, and decide for yourself.
Austin Frakt is a health economist at Boston University. He blogs at The Incidental Economist, which he created.
The purposes of comprehensive health reform are noble: expansion of coverage and control of costs. Yet, the latest attempt to begin to address those goals is near death. For nearly a year Democrats shepherded bills through the complex legislative process, revising and merging them to accommodate the congressional process and political realities. Ultimately two bills, similar in broad structure and differing only in detail, passed the chambers of Congress.Yet, at the brink of completion support for them has waned. What can be learned from this experience?
First, it is worthwhile appreciating how unlikely it is that policy-makers have brought health reform legislation this close to passage. It doesn’t clearly benefit all influential interest groups, a condition that normally dooms major reform. To have even pursued it was, therefore, a political risk. That Democrats, and Obama, took responsibility for attempting to solve the large and important problems of the uninsured and health care costs is laudable. In doing so they managed to mollify the concerns of major stakeholders.
My Washington decoder ring isn't the most finely tuned. But I think it's good enough to translate the message House leadership was trying to send yesterday: Don't take us for granted.
The message came most loudly, and most clearly, from Ways and Means Chairman Charles Rangel. For the last few weeks, observers (this one included) have been suggesting that keeping the requisite sixty senators in line will be difficult--and that, as a result, final legislation will look a lot more like the Senate version than its House counterpart.
That would mean, regrettably, covering fewer people and guaranteeing less comprehensive coverage than the House bill would. It'd also mean a lesser requirement on employers, taking less money from the drug and insurance industries, and accepting some sort of tax on the most expensive health benefits.
But Rangel, in an interview with Roll Call, suggested that straying too far from the House bill could also threaten the bill's success, because the original House bill barely passed--and House liberals, in particular, are in no mood to roll over for the Senate.
We’ve got a problem on both sides of the Capitol. A serious problem. ... The difficulty in hashing out an agreement between the two chambers is largely due to there being so many different factions with a stake in the matter ... Normally you’re just dealing with the Senate and they talk about 60 votes and you listen to them and cave in, but this is entirely different ... I’m telling you that never has 218 been so important to me in the House.
It wasn't just Rangel saying this.
Allan Sloan, in a column criticizing the proposed tax on expensive health insurance plans, says that most of the revenue from this tax wouldn't come from the high-cost plans:
Readers may have noticed that the "Daily Treatment" isn't really daily. Instead, it's daily when I have time to write it, which isn't as often as I would like. And that's unfortunate.
It means I don't get to chance to highlight many worthy articles--or, more important, to thank, implicitly, the writers and thinkers whose work influences me. So today I'm bringing the Daily Treatment back, but offering an extended holiday version--one in which I can give thanks to...
Julie Appleby, Mary Agnes Carey, Philip Galewitz, and Jordan Rau for asking, and answering, the questions most Americans actually care about
Carrie Budoff Brown for her relentless, indispensable coverage
Brian Beutler for being impervious to spin (and nearly impervious to bullets)
Michael Cannon for keeping me honest
Kevin Drum for staying healthy
More competition among insurers isn't always a good thing. (Austin Frakt, Incidental Economist)
Dealing with Medicare is usually easier (or at least less difficult) than dealing with private insurers. (Joe Paduda, Managed Care Matters)
Doctors, who didn't win repeal of Sustainable Growth Rate formula in Medicare (Jay Newton-Small, Time)
The insurance industry, which has turned out to be its own worst enemy (Paul Waldman, The American Prospect)
