September 21st, 2009
Truth is not only the first casualty of war, it is also the first casualty of serious public policy debate.
Last year, a report by Families USA made the astounding claim that 6 people die every day in Florida because they are uninsured. Seven die every day in Texas, 8 in California, and 25 in New York.
How was Families USA able to tally up all that carnage with such pinpoint precision? As Linda Gorman explains, these claims are based on a 15-year cascade of studies — each repeating the errors and misinterpreting or mischaracterizing the findings of the previous one and ultimately relying on data that is 37 years old.
It begins with a paper by Peter Franks et al. published in the Journal of the American Medical Association in 1993, estimating that being uninsured increased the probability of death by 25%. Although the subjects were interviewed only once, for the study’s inference to be meaningful, one is forced to make the unverified assumption that the uninsured stayed uninsured for a full 19 years!
Continuing the saga, the Institute of Medicine (IOM) uncritically used the Franks result to claim that 18,000 deaths a year in the U.S. are attributable to a lack of health insurance. The Urban Institute updated the IOM report, and Families USA updated the Urban Institute report.
Physicians for a National Health Program Produces The Latest In A String Of Flawed Studies
Not to be outdone, Physicians for a National Health Program (PNHP) has just repeated the exercise (with all its methodological sins) and boosted the tally to a 40% increase in the probability of dying for the uninsured. That produces a whopping 45,000 premature deaths every year — almost as bad as the Vietnam War. And, yes, we get a state-by-state breakdown. There will be 5,302 deaths attributed to uninsurance in California this year. There will be 75 in Wyoming, etc., etc. There is even a minute-by-minute tally: “The Institute of Medicine, using older studies, estimated that one American dies every 30 minutes from lack of health insurance,” says David Himmelstein, one of the authors. “Now one dies every 12 minutes.”
As in the previous incarnations, the researchers interviewed the uninsured only once — and never saw them again. A decade later, the researchers assumed the participants were still uninsured and, if they died in the interim, lack of insurance was blamed as one of the causes.
Yet, like unemployment, uninsurance happens to many people for short periods of time. Most people who are uninsured regain insurance within one year. The authors of the PNHP study did not track what happened to the insurance status of the subjects over the decade examined, what medical care they received or even the causes of their deaths.
Also, before you go into mourning too quickly, be aware that when former Director of the Congressional Budget Office (CBO) June O’Neill and her husband Dave used a similar approach, they found that the involuntarily uninsured (low-income people) were only 3% more likely to die over a 14-year period than those with health insurance. There was no statistically significant effect on the “voluntarily uninsured” (higher-income people).
That’s not too surprising in light of a RAND study finding: Although people are receiving appropriate care a little better than half the time when they see doctors, the care they receive is not affected by whether they are insured or by the type of insurance they have. People who are uninsured, of course, may delay seeing a doctor in the first place — because of their lack of insurance. But this problem is unlikely to be solved by enrolling them in Medicaid programs that routinely ration by waiting.
The uninsured in the PNHP study are disproportionally poor, minority, high school dropouts and unemployed. Although the study ignores public insurance, bills before Congress would try to insure this group by expanding Medicaid. The O’Neills found that people enrolled in Medicaid have a much higher mortality rate than the uninsured. In other words, Medicaid enrollment reduces life expectancy rather than increasing it!
Even more odd, the PNHP authors are on record as favoring Canada’s system of single-payer national health insurance. Yet insured patients in Canada fare worse than the uninsured in the United States. The O’Neills found that:
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• Among US women age 40 to 64, 87% of those with insurance had a mammogram within 5 years.
• The rate for Canadian women was 65% — the same as for uninsured women in the US.
• Canadian women also had the same rate of screening for cervical cancer as uninsured US women (80%), over five years. Among insured US women, the rate was 92%.
• Among uninsured US men, 31% were screened for prostate cancer, compared with 16% of Canadian men. For insured US men, the rate was 52%.