Yes, Health Insurance Saves Lives

May 6, 2013 6:45 a.m.

There have been so many hasty and opportunistic reactions to the famed Oregon Medicaid study that containing the spread of misinformation is a bit like standing athwart a tsunami yelling “stop!” Moreover, people like Aaron Carroll and Austin Frakt are much more qualified to comment on it and have been doing an excellent job, so I’d really recommend you read their recent posts on the subject.

But to draw attention to one of Medicaid critics’ most effective sleights of hand, performed most recently and deftly by Ross Douthat, consider the following thought experiment.

Imagine a year-long study of 2000 uninsured people, 1000 of whom were allowed to enroll in Medicaid, the other 1000 of whom were required to remain uninsured. After a year, the aggregate data indicated that Medicaid provided the first 1000 significant economic security and measurable mental health benefits, but showed negligible (or more likely inconclusive) effects on heart health.

Not evident from the aggregate data, though, was that mid-way through the study, one male subject from each group began experiencing chest pains. After a few days, the man with Medicaid went to the hospital, had an abnormal EKG and an emergency angiogram, which revealed a major blockage and required immediate angioplasty. He survived. The man without Medicaid, by contrast, did nothing, until he suffered a massive MI, and died in an ambulance on the way to the hospital.

In other words, it’s possible that being uninsured cost one of my made up subjects his life, even though the made up study didn’t find significant overall improvement in measures of cardiac health. Likewise in the real world, the Oregon study was not designed to address the excess deaths issue, just like studies on insurance’s impact on mortality aren’t designed to test its impact on various health measures across the population.

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But of course, most real-world excess death studies link tens of thousands of deaths a year to uninsurance. That’s a very small percentage of the millions of uninsured in the United States. But I doubt even Medicaid’s loudest critics would shrug off 10,000 or 20,000 preventable deaths a year in most other contexts.

So instead they put their heads in the sand. Douthat more or less treats the Oregon study as a de facto refutation of that entire, separate area of research.

“[T]he health care law was sold, in part, with the promise (made by judicious wonks as well as overreaching politicians) that it would save tens of thousands of American lives each year,” he writes. “There was so much moral fervor on the issue, so much crusading liberal zeal, precisely because this was not supposed to be just a big redistribution program: it was supposed to be a matter of life and death. But if it turns out that health insurance is useful mostly because it averts financial catastrophe — which seems to be the consensus liberal position since the Oregon data came out — then the new health care law looks vulnerable.”

I would say two things. First: financial security for millions of people is a huge deal on its own and ACA’s critics need to contend with the fact that repealing the law will impoverish hundreds of thousands relative to a scenario in which the law is fully implemented. But also, it’s completely possible that though the most common benefit of health insurance is economic, it has the ancillary benefit of preventing some deaths. Those are both very strong reasons to support extending Medicaid coverage to millions more people, just as the ACA envisions.

But I would not say that the Medicaid study disproves ACA supporters who point out insurance is a matter of life and death. Here’s how Frakt put it to me in an email.

It’s absolutely the case that the most recent study from the Oregon Health Insurance Experiment is uninformative about physical health due to low sample. Consequently, it is also uninformative about mortality. If your hypothetical occurred in the study population, we’d not be able to say with any statistical precision anyone would buy that insurance saved a life. Nor could we say it didn’t. So, whatever one’s prior position was on the direct insurance-mortality link, it shouldn’t change one iota based on this study. Indirectly, the study should actually increase your view that there is such a link to the extent you think access to mental and physical health care ever saves lives. We all believe that at least a little, right?

As a postscript, I’d also acknowledge that my thought experiment ignores offsetting scenarios in which people die from bad care or over treatment that they might not have received if they’d been uninsured. But I think we can all agree that the two scenarios are morally very different, and moreover among the many things the ACA attempts to do is transition away from fee for service medicine so that providers are paid for better outcomes.

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