At Least a Third of What We Spend on Health Care Is Wasted--and We Don't Spend Enough
Michael McWilliams:
Letting Perfect be the Enemy of Good?: An Atlantic Monthly article by Megan McArdle questions whether health insurance coverage saves lives, drawing from a narrow slice of the literature to suggest the beneficial effects of insurance coverage on mortality might be negligible. While it is true these effects have been challenging for researchers to assess accurately, this question deserves more than a selective reading of the literature to inform the public and policymakers properly. Indeed, when reviewed comprehensively and with an understanding of key clinical and methodological nuances, the research to date provides consistent and compelling evidence that health insurance coverage significantly improves health outcomes, particularly for adults with treatable conditions (McWilliams 2009)....
Studies on the health consequences of uninsurance can be broadly categorized as observational or quasi-experimental. Observational studies... are fundamentally limited because it is usually impossible to control for all possible differences and some differences may be both causes and consequences of insurance coverage.... McArdle selects just one negative study to suggest insurance coverage may not affect mortality (Kronick 2009). Yet several other observational studies that controlled for an equally robust set of characteristics have consistently demonstrated a 35-43% greater risk of death within 8-10 years for adults who were uninsured at baseline and even higher relative risks for older uninsured adults with treatable chronic conditions such as diabetes and hypertension (Baker et al. 2006; McWilliams et al. 2004; Wilper et al. 2009)....
From the quasi-experimental literature, McArdle cites evidence of a lack of immediate survival gains with near-universal Medicare coverage after age 65 in the general population (Card et al. 2004; Levy, and Meltzer 2008). From a clinical perspective, however, we should not expect immediate survival gains for most previously uninsured adults because mortality is such a distal outcome.... Quasi-experiments that rely on abrupt discontinuities occurring with age are not well suited to capturing these complex but potentially large effects. Consequently, the absence of evidence suggested by these studies is not evidence of absence.... [I]mmediate mortality effects might be expected for acutely ill patients for whom coverage may improve access to life-saving procedures and therapies. Indeed, a more recent study found age-eligibility for Medicare was associated with a substantial and lasting reduction in mortality for patients who were hospitalized for a range of acute illnesses that were amenable to treatment (Card et al. 2009).
Because many quasi-experimental strategies are geared to capture effects of insurance coverage only if they occur in the short term, they are better suited to examining proximal or intermediate health outcomes. Therefore, perhaps more can be learned about the effects of insurance coverage on mortality from studies that rigorously examine effects on health outcomes that are highly predictive of mortality... numerous studies have found consistently beneficial and often significant effects of insurance coverage on health across a comprehensive set of outcomes and a broad range of treatable chronic and acute conditions that affect many adults in the U.S., including hypertension, coronary artery disease, congestive heart failure, stroke, diabetes, HIV infection, depressive symptoms, acute myocardial infarction, acute respiratory illnesses, and traumatic injuries (McWilliams 2009). In particular, several studies have robustly demonstrated positive effects of near-universal Medicare coverage after age 65 on self-reported health outcomes and clinical measures of disease control, particular for adults with cardiovascular disease or diabetes who make up two-thirds of the near-elderly (Decker and Remler 2004; McWilliams et al. 2007, 2009). Thus, when rigorous study designs have been coupled with appropriate outcomes and applied to clinical populations for whom medical care is effective, the evidence that insurance coverage improves health and survival is consistent and convincing...
