The Opposite Of Life Is Indifference

The Atlantic once again commissions Megan McArdle to put her mad math skillz, expertise in statistics and methodology, and razor-sharp logic to determine if the lack of health insurance, and therefore health care, results in the deaths of our fellow Americans.

If we lost our [health] insurance, would this gargantuan new entitlement [the health insurance reform bill] really be the only thing standing between us and an early grave?

The obvious answer is yes. If you can't afford health insurance, and therefore can't afford health care, you will be in grave danger of losing your life if you develop a fatal illness or injury. That fact is simply self-evident. Severe accidents don't heal themselves. Fatal illnesses must be treated. If you need a doctor and can't afford to go to one, you might not recover.

It's not easy to deny the obvious, to ignore simple fact. Thinking people don't need to puzzle out if getting medical attention is better than not getting medical attention. It is not even up for debate unless you just don't want to accept reality, for personal or financial reasons. Then you must put on your spangled gown, blare the John Phillip Sousa march, set your baton on fire, and twirl your little heart out.

Outside of the few states where it is illegal to deny coverage based on medical history, I am probably uninsurable. Though I’m in pretty good health, I have several latent conditions, including an autoimmune disease. If I lost the generous insurance that I have through The Atlantic, even the most charitable insurer might hesitate to take me on.

So I took a keen interest when, at the fervid climax of the health-care debate in mid-December, a Washington Post blogger, Ezra Klein, declared that Senator Joseph Lieberman, by refusing to vote for a bill with a public option, was apparently “willing to cause the deaths of hundreds of thousands” of uninsured people in order to punish the progressives who had opposed his reelection in 2006.

Her first lie. She doesn't want the the denial of coverage to be reformed despite her illnesses, not because of her illnesses; she specifically said so. From: A Long, Long Post About My Reasons For Opposing National Health Care:

At this juncture in the conversation, someone almost always breaks in and says, "Why don't you tell that to an uninsured person?" I have. Specifically, I told it to me. I was uninsured for more than two years after grad school, with an autoimmune disease and asthma. I was, if anything, even more militant than I am now about government takeover of insurance.

It takes an incredibly sleazy hack to try to manipulate her audience by claiming victim status and trolling for the audience's sympathy. It is the technique of a two-bit con-woman, who sizes up her audience at a glance and insinuates herself by pretending to be like the mark, claiming to have the same interests or occupation or biases. If she has to make two totally contradictory statements to achieve her goal, facts, logic and reality are not even factors in her decision making process. Deceiving the mark is the only reality.

In the ensuing blogstorm, conservatives condemned Klein’s “venomous smear,” while liberals solemnly debated the circumstances under which one may properly accuse one’s opponents of mass murder.

McArdle does not provide any quotes to support her hysterical accusation; it is merely sufficient to make an unprofessional claim that one's opponents debate how to best make false accusations.

But aside from an exchange between Matthew Yglesias of the Center for American Progress and Michael Cannon of the Cato Institute, few people addressed the question that mattered most to those of us who cannot buy an individual insurance policy at any price—the question that was arguably the health-care debate’s most important: Was Klein (not to mention other like-minded editorialists who cited similar numbers) right? If we lost our insurance, would this gargantuan new entitlement really be the only thing standing between us and an early grave?

We've seen people make decisions that harm themselves and others countless times as people vote against their personal interests, but most of these people don't have an MBA from the University of Chicago.

McArdle finally introduces her topic: Being unable to afford medical insurance will not harm your health. McArdle is going to be tested to the limits to attempt to pull off this maneuver. First, she lays the groundwork by acknowledging that her statement is moronic. She could hardly do otherwise, although that's never stopped her before.

Perhaps few people were asking, because the question sounds so stupid. Health insurance buys you health care. Health care is supposed to save your life. So if you don’t have someone buying you health care well, you can complete the syllogism.

So, why is this statement not moronic?

Last year’s national debate on health-care legislation tended to dwell on either heart-wrenching anecdotes about costly, unattainable medical treatments, or arcane battles over how many people in the United States lacked insurance.

McArdle is saying that the debate relied on anecdotes or "arcane" information to determine the number of people unable to afford health care because of cost, and the number of uninsured. Arcane means "known or understood by very few; mysterious; secret; obscure; esoteric," so according to McArdle it should be nearly impossible to find any information on the subject. Of course she is utterly wrong, which we will cover later.

Republicans rarely plumbed the connection between insurance and mortality, presumably because they would look foolish and heartless if they expressed any doubt about health insurance’s benefits.

Well, yes, but we know that will not stop people who have repressed any empathy for any other living creature.

It was politically safer to harp on the potential problems of government interventions—or, in extremis, to point out that more than half the uninsured were either affluent, lacking citizenship, or already eligible for government programs in which they hadn’t bothered to enroll.

Oh, McArdle is being daring to make utterly ludicrous and false statements.

Even Democratic politicians made curiously little of the plight of the uninsured.

There will, of course, be no quotes or names to back up this statement.

Instead, they focused on cost control, so much so that you might have thought that covering the uninsured was a happy side effect of really throttling back the rate of growth in Medicare spending. When progressive politicians or journalists did address the disadvantages of being uninsured, they often fell back on the same data Klein had used: a 2008 report from the Urban Institute that estimated that about 20,000 people were dying every year for lack of health insurance.

But when you probe that claim, its accuracy is open to question. Even a rough approximation of how many people die because of lack of health insurance is hard to reach. Quite possibly, lack of health insurance has no more impact on your health than lack of flood insurance.

Now McArdle can settle comfortably into her favorite technique of weakly poking holes until she deems she has done enough damage to sow doubt. She doesn't need to prove anything. She doesn't even need to disprove anything. She just needs to look like she kind of knows what she is talking about, and--most important of all--that you do not.

Part of the trouble with reports like the one from the Urban Institute is that they cannot do the kind of thing we do to test drugs or medical procedures: divide people randomly into groups that do and don’t have health insurance, and see which group fares better. Experimental studies like this would be tremendously expensive, and it’s hard to imagine that they’d attract sufficient volunteers. Moreover, they might well violate the ethical standards of doctors who believed they were condemning the uninsured patients to a life nasty, brutish, and short.

So instead, researchers usually do what are called “observational studies”: they take data sets that include both insured and uninsured people, and compare their health outcomes—usually mortality rates, because these are unequivocal and easy to measure. For a long time, two of the best studies were Sorlie et al. (1994), which used a large sample of census data from 1982 to 1985; and Franks, Clancy, and Gold (1993), which examined a smaller but richer data set from the National Health and Nutrition Examination Survey, and its follow-up studies, between 1971 and 1987. The Institute of Medicine used the math behind these two studies to produce a 2002 report on an increase in illness and death from lack of insurance; the Urban Institute, in turn, updated those numbers to produce the figure that became the gold standard during the debate over health-care reform.

The first thing one notices is that the original studies are a trifle elderly. Medicine has changed since 1987; presumably, so has the riskiness of going without health insurance. Moreover, the question of who had insurance is particularly dodgy: the studies counted as “uninsured” anyone who lacked insurance in the initial interview. But of course, not all of those people would have stayed uninsured—a separate study suggests that only about a third of those who reported being uninsured over a two-year time frame lacked coverage for the entire period. Most of the “uninsured” people probably got insurance relatively quickly, while some of the “insured” probably lost theirs. The effect of this churn could bias your results either way; the inability to control for it makes the statistics less accurate.

I have never taken a class on statistics, can barely multiply, and can only figure out percentages because I buy a lot of things on sale, but even I can detect the wafting of bullshit coming off these statements. McArdle does not tell us how medicine has changed since 1987, or how those supposed changes made it less or more risky to be without insurance. We are to take her assumptions as facts, and our facts as assumptions. McArdle doesn't like the number of uninsured, so she says that if you're insured some of the time, you don't count as uninsured any of the time. McArdle doesn't need to research; she simply knows the facts intuitively.

The majority of the uninsured have been without insurance for a long time. Nearly 6 in 10 uninsured adults (59%) have been without insurance for over 2 years. (Chart 4)

Oops.

If McArdle didn't like the Urban Institute Study she could have used recent information from the CDC. The Centers for Disease Control and Prevention reported: [pdf]

In 2008, 6.5% (95% confidence interval = 6.17%–6.87%) of the population failed to obtain needed medical care due to cost at some time during the past 12 months, which was higher than the 2007 estimate of 5.8%.

From 1998 to 2008, there was a generally increasing trend in the annual percentage of persons who failed to obtain medical care due to cost (from 4.2% in 1998 to 6.5% in 2008).

Gosh, that was kind of easy to find. Look, here's more from the Commonwealth Fund.

TUESDAY, July 21 (HealthDay News) -- Most people in the United States who try to buy an individual health insurance policy on their own never end up getting coverage, often because the premiums are just too expensive, according to a new study.

A report by the Commonwealth Fund, a private foundation that supports independent research on health policy reform, found that roughly three of every four people who tried to buy a policy from the individual health insurance market in the past three years didn't get one. The main reason cited was premium cost. About 57 percent said it was very hard or even impossible to find coverage they could afford.

About 47 percent of the people surveyed said it was difficult or impossible to find a plan with the coverage they needed, and 36 percent reported being charged more or denied coverage because of a pre-existing condition or had the condition excluded from their coverage.

In one of the many amusing posts McArdle has made to defend her lies, she claims The Commonwealth Fund is biased in favor of health insurance reform, so let's see who they are.

The Commonwealth Fund is a charitable foundation established in 1918 by Anna Harkness (wife of one of the original Standard Oil investors, Stephen Harkness). Charged with the mandate to "do something for the welfare of mankind," Ms. Harkness founded the organization with an initial endowment of $10 million dollars. Her son Edward Harkness served as its first president, and through additional gifts and bequests between 1918 and 1959, the Harkness family's total contribution to the Fund's endowment amounted to more than $53 million.

The Fund is one of the major philanthropic foundations in the United States today and one of the few established by a woman. Over the years, it has given support to medical schools and to the building of hospitals and clinics in rural areas. In New York City, the Commonwealth Fund was a major contributor to the building of Columbia-Presbyterian Medical Center of the College of Physicians and Surgeons and Presbyterian Hospital at Columbia University in 1922.

[snip]

The Fund is currently led by president Karen Davis, a nationally recognized economist, with an extensive background in public policy and research. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at the Johns Hopkins School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977–1980, and was the first woman to head a U.S. Public Health Service agency. Prior to her government career, Ms. Davis was a senior fellow at the Brookings Institution in Washington, D.C., a visiting lecturer at Harvard University, and an assistant professor of economics at Rice University. A native of Oklahoma, she received her Ph.D. in economics from Rice University.

The Fund states that it is pro-health care reform, which in McArdle's mind makes it hopelessly biased and untrustworthy. After all, she is biased and untrustworthy, so wouldn't everyone else be the same?

The bigger problem is that the uninsured generally have more health risks than the rest of the population. They are poorer, more likely to smoke, less educated, more likely to be unemployed, more likely to be obese, and so forth. All these things are known to increase your risk of dying, independent of your insurance status.

McArdle ignores the financial causes of poor health in favor of causes she prefers, ones that she can blame on the uninsured instead of innocent, suffering insurance companies. For instance:

III. What Difference Does Not Having Health Insurance Make?
• The uninsured are less likely than the insured to have a regular place they go for medical advice. While the majority of the insured and uninsured say they have a regular place to go when they are sick or need medical advice, the insured (91%) are more likely than the uninsured (64%) to have a place to go (Chart 7). When asked where they go when they need medical care, the majority (68%) of the insured say a doctor’s office, compared to 34% of the uninsured who say they go to a doctor’s office.(Chart 8)
• The uninsured are also much less likely than the insured to have received preventive care. The uninsured are much less likely than the insured to have received preventive services in the past year such as mammograms (16% vs. 40%) and pap smears (49%vs. 76%) among women, prostate exams (12% vs. 20%) among men, and routine physical examinations (47% vs. 70%). (Chart 9)
• The uninsured are more likely than the insured to have skipped, postponed, or had problems getting medical care. The uninsured are more likely than the insured to have skipped medical treatments (39% vs. 13%), had problems getting mental health care (13% vs. 4%), or not filled prescriptions (30% vs. 12%) because of the cost. The uninsured are also more likely than the insured to have not received needed care (26% vs. 4%) or to have postponed care (39% vs. 10%) in the past year. Furthermore,the uninsured say that many of the medical problems that they delayed or postponed treatment for were serious problems. The uninsured are more likely than the insured to say they have not received needed care for serious problems (20% vs. 3%) or have
postponed care for serious problems (28% vs. 5%) in the past year. (Charts 10 and 11)
• The uninsured are more likely than the insured to have problems paying medical bills. The uninsured are more likely than the insured to have had problems paying medical bills (39% vs. 18%) and to have ever been contacted by a collection agency for medical care expenses (39% vs. 27%). (Chart 12)
• Many of the uninsured say they would have to give up basic necessities in order to buy health insurance. While half (51%) of the uninsured say that health insurance ranks high as a priority for where they spend their money, 3 in 4 (76%) of the uninsured say they would have to give up things to buy health insurance. Of those who say they would have to give up things to buy health insurance, 53% (40% of all of the uninsured) say they would have to cut back on necessities such as food, rent, and utility bills.(Chart 13)

Having satisfactorily disposed of the facts, McArdle happily moves on to just making shit up.

There are also factors we can’t analyze. It’s widely believed that health improves with social status, a quality that’s hard to measure. Risk-seekers are probably more likely to end up uninsured, and also to end up dying in a car crash—but their predilection for thrills will not end up in our statistics. People who are suspicious of doctors probably don’t pursue either generous health insurance or early treatment. Those who score low on measures of conscientiousness often have trouble keeping jobs with good health insurance—or following complicated treatment protocols. And so on.

The studies relied upon by the Institute of Medicine and the Urban Institute tried to control for some of these factors. But Sorlie et al.—the larger study—lacked data on things like smoking habits and could control for only a few factors, while Franks, Clancy, and Gold, which had better controls but a smaller sample, could not, as an observational study, categorically exclude the possibility that lack of insurance has no effect on mortality at all.

For a proper refutation of McArdle's McFacts, see "Letting Perfect Be The Enemy Of Good?" at The Incidental Economist, who makes up in actual knowledge what he or she lacks in sarcasm.

You're probably exhausted by now, but you have to stick around for the next bit. It's a pisser.

This result is not, perhaps, as shocking as it seems. Health care heals, but it also kills. Someone who lacked insurance over the past few decades might have missed taking their Lipitor, but also their Vioxx or Fen-Phen. According to one estimate, 80,000 people a year are killed just by “nosocomial infections”—infections that arise as a result of medical treatment. The only truly experimental study on health insurance, a randomized study of almost 4,000 subjects done by Rand and concluded in 1982, found that increasing the generosity of people’s health insurance caused them to use more health care, but made almost no difference in their health status.

It's okay if people die for the lack of health insurance, because sometimes doctors kill people! Not that anyone dies for the lack of health insurance, however! Likewise you should never eat, for sometimes people who eat are killed by what you eat!

If gaining insurance has a large effect on people’s health, we should see outcomes improve dramatically between one’s early and late 60s. Yet like the Kronick and Rand studies, analyses of the effect of Medicare, which becomes available to virtually everyone in America at the age of 65, show little benefit. In a recent review of the literature, Helen Levy of the University of Michigan and David Meltzer of the University of Chicago noted that the latest studies of this question “paint a surprisingly consistent picture: Medicare increases consumption of medical care and may modestly improve self-reported health but has no effect on mortality, at least in the short run.”

Of course, that might be an indictment of programs like Medicare and Medicaid. Indeed, given the uncertainties about their impact on mortality rates—uncertainties that the results from Sorlie et al. don’t resolve—it’s possible that, by blocking the proposed expansion of health care through Medicare, Senator Lieberman, rather than committing the industrial-scale slaughter Klein fears, might not have harmed anyone at all. We cannot use one study to “prove” that having government insurance is riskier than having none. But we also cannot use a flawed and conflicting literature to “prove” that Lieberman was willing to risk the deaths of hundreds of thousands. Government insurance should have some effect, but if that effect is not large enough to be unequivocally evident in the data we have, it must be small.

Klein responds to McArdle on Medicare here, pointing out the weakness of her positon and, again, that holding out for the perfect study doesn't work in the real world. (It works great if all you want to do is cast aspersions, however.) Since McArdle habitually confuses Medicare and Medicaid, I'll take Klein's word over McArdle's.

Even if we did agree that insurance rarely confers significant health benefits, that would not necessarily undermine the case for a national health-care program. The academics who question the mass benefits of expanding coverage still think that doing so improves outcomes among certain vulnerable subgroups, like infants and patients with HIV. Besides, a national health program has nonmedical benefits. Leaving tens of millions of Americans without health insurance violates our sense of equity—and leaves those millions exposed to the risk of mind-boggling medical bills.

But we should have had a better handle on the case for expanded coverage—and, more important, the evidence behind it—before we embarked on a year-long debate that divided our house against itself. Certainly, we should have had it before Congress voted on the largest entitlement expansion in 40 years. Unfortunately, most of us forgot to ask a fundamental question, because we were certain we already knew the answer. By the time we got around to challenging our assumptions, it was too late to do anything except scream at each other from the sidelines.

McArdle so dislikes the vituperation of the other side, which meanly and stridently insists on facts over opinion, reality over prejudice, and logic over wishful thinking.

In the mantime, wait. Do nothing. Start over from scratch. There's no hurry; it's not like anyone's dying here.