Wednesday, April 11, 2007

Hacks and healthcare.

You can tell this is an odd US federal election coming up next year, for the right-wing hacks are coming out of the woodwork to raise all the old bugbears about universal health insurance. Let us point and laugh at this little piece from two Cato Institute drones.
Many countries provide universal insurance but deny critical procedures to patients who need them. Britain's Department of Health reported in 2006 that at any given time, nearly 900,000 Britons are waiting for admission to National Health Service hospitals, and shortages force the cancellation of more than 50,000 operations each year.
Argument by meaningless "scary" stats. How many operations are cancelled in the US? How many Americans can't get access to hospitals? As far as the drones are concerned, context doesn't matter; 900,000 is a big number, and that's enough to frighten the peons into voting Republican!
In Sweden, the wait for heart surgery can be as long as 25 weeks, and the average wait for hip-replacement surgery is more than a year. Many of these individuals suffer chronic pain, and judging by the numbers, some may well die awaiting treatment. In a 2005 ruling of the Canadian Supreme Court, Chief Justice Beverly McLachlin wrote that "access to a waiting list is not access to health care."
This is just sad. The numbers they're quoting for heart surgery make no distinction between people who need a quadruple bypass and people who are waiting for exploratory procedures. There's not, on the face of it, any reason to suppose that it's the former who are having their surgeries delayed, yet that is exactly the conclusion the drones draw. Furthermore, the citation of the wait-times for hip-replacements is irrelevant: living in "chronic pain" (which is actually a technical medical term, but never mind) may suck, but if it's a choice between that and people dying of preventable diseases, then the correct choice is clear. (And this is all ignoring the fact that these stats are, also, given without context.)

Finally, citing McLachlin is simply bizarre. Because she's a judge that means she can't be wrong?

Here comes a howler:
Supporters of universal coverage fear that people without health insurance will be denied the healthcare they need. Of course, all Americans already have access to at least emergency care. Hospitals are legally obligated to provide care regardless of ability to pay, and although physicians do not face the same legal requirements, we do not hear of many who are willing to deny treatment because a patient lacks insurance.
Oh. My. God. I don't think they could have more effectively missed the point if they'd tried. First, hospitals are required to provide care regardless of ability to pay if one is actually in need of emergency care. They can refuse to provide care if they judge that care is not necessary. Since there's a big gap between "in need of urgent care" and "perfectly healthy", there's a clear problem. Second, that we don't hear of physicians who deny treatment due to lack of ability to pay doesn't mean it doesn't happen. Third, the issue is more about the uninsured or underinsured deliberately refusing to seek care -- or, worse, deliberately refusing care that is medically indicated -- because of their inability to pay.
You might think it is self-evident that the uninsured may forgo preventive care or receive a lower quality of care.
You will be forgiven for thinking this is a prelude to a reasonable assessment of an important issue.
And yet, in reviewing the academic literature on the subject, Helen Levy of the University of Michigan's Economic Research Initiative on the Uninsured and David Meltzer of the University of Chicago, were unable to establish a "causal relationship" between health insurance and better health. Believe it or not, there is "no evidence," Ms. Levy and Mr. Meltzer wrote, that expanding insurance coverage is a cost-effective way to promote health.
I'll ignore the annoying dropping of Meltzer and Levy's deserved "Dr." honorifics (after all, this may be the copy-editor's doing). And the drones know damn well that one paper doesn't prove a case. But, let's actually go find the paper in question, shall we? According to Meltzer's CV (.pdf) and Levy's webpage (here), the paper was published as a book chapter, and it's not one that York has as an e-book. But wait! Levy has a working paper version available on her webpage (.pdf). And, from the fucking abstract:
Very few of these studies, however, establish a causal relationship between health insurance and health. Causation is difficult to establish because we almost never observe truly random variation in health insurance status. Instead, people who have health insurance and people who do not almost certainly differ in many ways in addition to the difference in their health insurance coverage. Moreover, the causal relationship between health insurance and health is likely to run in both directions; health status may affect insurance coverage and insurance may affect health. This makes it difficult to determine whether a correlation between health insurance and health status reflects the effect of health insurance on health, the effect of health on health insurance, or the effect of some other attribute, such as socioeconomic status, on both health insurance and health status.
So, because of technical problems in establishing causal relationships, Levy and Meltzer are counselling caution in drawing causal conclusions. And, reading the abstract still further:
Our critical review of the literature on this question suggests that when we restrict our attention to studies that convincingly address the endogeneity of health insurance, the bulk of the evidence suggests there is a small, positive effect of insurance coverage on health outcomes among the populations most likely to be the targets of public coverage expansions: infants, the elderly, and the poor. There is also evidence to suggest that in some cases, expansions in health insurance may not result in measurable improvements in health.
In other words, where they can establish a causal relationship, expanding insurance coverage has a positive effect, although a small one, on health outcomes. In other cases, there are no measureable improvements in health -- which, if we read higher up in the abstract, is partially explained by this:
Second, health itself is also a complex, multidimensional construct, and our ability to measure it is imperfect.
And, I couldn't let this little gem go by:
the most plausible pathway through which health insurance may have a causal effect on health is through improved access to medical care: having health insurance increases the quality and/or quantity of medical care, which in turn improves health.
In other words, Levy and Meltzer proceed by presuming that the drones' central claim is false.

Of course, strictly, the drones are cleverer than this: they actually don't say there is no causal relationship between health insurance and improved health; they simply allow the reader to infer that from their claims. Which is blatantly dishonest, but not an outright lie.
Similarly, a study published in the New England Journal of Medicine last year found that, although many Americans were not receiving the appropriate standard of care, "health insurance status was largely unrelated to the quality of care."
I simply couldn't find this study. I'd be surprised, though, if their report of its results was any more accurate than their report of Levy and Meltzer's paper.

It does get even worse, shockingly.
Another common concern is that the young and healthy will go without insurance, leaving a risk pool of older and sicker people. This results in higher insurance premiums for those who are insured. But that's only true if the law forbids insurers from charging their customers according to the cost of covering them. If companies can charge more to cover people who are likely to need more care – smokers, the elderly, and others – then it won't make any difference who does or doesn't buy insurance.
This is completely insane. If companies charge more to cover those who need more care, then that creates an incentive for those who need more care to refuse insurance. In other words, the weak and vulnerable are sacrificed in favour of the strong and powerful. How this is a good thing is opaque to me.

Furthermore, in the case of "smokers, the elderly, and others", it's at least as likely that insurers will either refuse to provide insurance or revoke insurance once a health condition comes to light as it is they will simply increase premiums (ignoring that increases could go beyond ability to pay, which would accomplish the same thing as refusing to provide insurance). So, if you are, genetically, predisposed to develop diabetes (Type 1), you can either reveal or not reveal this information to your insurer. If you do, they may charge you double -- or triple, or whatever -- premiums, or they may simply refuse to insure you, leaving you on your own to obtain the insulin necessary to keep you alive, should diabetes develop. If you don't, and diabetes develops, then the insurer may decide to cancel your policy, on the grounds that you lied to them. Thus, again, leaving you to obtain the insulin you need in order to live entirely on your own.

That is one of the central concerns of advocates of public, universal health insurance (and, indeed, universal pharmacare, dental coverage, etc, etc.). And the drones blow right by it.

In short, if companies can charge more, it will make a different to who does and doesn't have insurance. To assert otherwise is simply to lie.
Finally, some suggest that when people without health insurance receive treatment, the cost of their care is passed along to the rest of us. This is undeniably true. Yet it is a manageable problem. According to Jack Hadley and John Holahan of the left-leaning Urban Institute, uncompensated care for the uninsured amounts to less than 3 percent of total healthcare spending – a real cost, no doubt, but hardly a crisis.
According to The National Coalition on Health Care (no clue if the data's reliable; it's the first thing that came up on Google for "total healthcare spending us"), spending in the US on healthcare in 2004 was $1.9 trillion. 3% of that is $57 billion. I'm elated that $57 billion is a "real cost" in the eyes of the drones. I also note, in passing, that the way in which this problem could be managed is left entirely unaddressed; we are, apparently, supposed to take their word for it that it can be done. I would suggest that the best -- read: fairest and most cost-effective -- way to do so would be to simply insure the uninsured.
Everyone agrees that too many Americans lack health insurance. But covering the uninsured comes about as a byproduct of getting other things right. The real danger is that our national obsession with universal coverage will lead us to neglect reforms – such as enacting a standard health-insurance deduction, expanding health-savings accounts, and deregulating insurance markets – that could truly expand coverage, improve quality, and make care more affordable
I'm confused here, honestly. How does a standard health-insurance deduction differ from a universal healthcare premium? How are HSAs supposed to handle the problem of uninsured people receiving treatment? And when the fuck has deregulation ever made anything better and more affordable? (Electricity market, I'm looking at you.) Do the drones just not live in the same world as the rest of us?
As H.L. Mencken said, "For every problem, there is a solution that is simple, elegant, and wrong." Universal healthcare is a textbook case.
Mencken also said this:
The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary.
This is why sane people try to back up their arguments with reasons, not with empty appeals to pseudoauthorities.


Dan said...

Fucking brilliant! I wish I had the patience and energy to disassemble every Cato publication in that manner.

ADHR said...

Thanks. ;)