Is the entire US healthcare system worthless?

Most Americans think that our healthcare system is worth spending a lot of money, but there is some research that indicates that it doesn’t make people healthier! For example, Ross Douthat criticized Republicans for not repealing Obamacare because he doesn’t think it is saving enough lives to be worth the expense:

It’s worth raising once again the most counterintuitive and frequently scoffed-at point that conservatives have made about Obamacare:

It probably isn’t saving many lives.

One of the most powerful arguments in the litany that turned moderate Republican lawmakers to jelly was that they were voting to “make America sick again,” to effectively kill people who relied on the Affordable Care Act for drugs and surgery and treatment….So far the evidence is conspicuously missing.

Kevin Drum explains why he strongly supports Obamacare although he agrees with Douthat that Obamacare isn’t saving many lives.

The words probably and many are doing a heavy lift here, but let’s set that aside. Douthat is almost certainly right. Here’s why:

People in the US don’t die much before age 65, so health insurance for working-age folks has never been likely to have much effect on death rates. Below age 55, it’s even less likely: the death rate is so minuscule that it would take a miracle to invent any kind of health-related practice that had a measurable effect on life expectancy. If the crude death rate is already below 0.5 percent, there’s just no way to reduce it much more.

And yet, people like health care anyway. They like it so much that we’re collectively willing to spend vast amounts of money on it. As you’ve probably heard many dozens of times, health care is one-sixth of the economy. On average, that means we all pay about one-sixth of our income to provide health care for ourselves.

Why? At the risk of repeating the obvious, most medical care isn’t about lifespan. Before age 65, almost none of it is about lifespan. It’s about feeling better. I’m taking a very expensive chemotherapy drug that probably won’t delay my eventual death by much, but it will improve my life considerably in the meantime. Ditto for the antidepressant I take. And for the arthroscopic knee surgery I had a couple of decades ago.

The same is true for putting a leg in a cast; prescribing an asthma inhaler; replacing a hip; treating an infection; inserting an IUD; treating a hernia; removing a cataract; prescribing a statin; or a hundred other medical procedures. Only a small percentage of what doctors do is lifesaving.

Julia Belluz reviews some of the research that doesn’t find health insurance improving health and gives five theories. Three of them are about errors in how we measure health improvements and the other two are condemnation of the entire health insurance (and medical) industries. Her first theory is a measurement error theory mostly like the above idea.

Studies often find that giving people health care doesn’t always improve health in measurable ways. A new NBER working paper has reignited that debate, looking at the people who gained coverage from the Affordable Care Act… They found that the ACA increased insurance coverage — by 5.3 percentage points in non-expansion states and 8.3 points in expansion states. The law also boosted the number of people who had a primary care doctor and checkups. But that increased coverage didn’t translate to better health outcomes after two years. …

So why doesn’t giving people health insurance lead to better health? The evidence on this question is quite mixed — this study isn’t the first to find less-than-stellar health gains after people get insurance. I think there are at least five compelling explanations:

1) [Health insurance has the biggest immediate benefits for people who are the sickest, but most people aren’t very sick.]. Consider just one of the seminal studies on the impact of health insurance, which focused on Oregon’s Medicaid expansion. The researchers found insurance improved people’s access to care, made them less depressed, reduced their financial strain, and improved their perceptions of their health and well-being — but it didn’t improve blood sugar control or their prevalence or diagnosis of high blood pressure or high cholesterol. It also didn’t influence their use of medications for these conditions.

In the new NBER paper, one group — older adults — seemed to be healthier after the ACA. Courtemanche thought this was probably because they were sicker to begin with and needed the most care. When they got coverage, their health improved, unlike younger people who may not have had as many health conditions.

2) [This is a condemnation of our health system] The health system isn’t great at addressing the chronic health issues that sicken people these days. So much of why we’re unhealthy has to do with our behaviors and environments. We don’t eat healthy diets, we smoke too much, we don’t exercise, we live in communities that are polluted or unwalkable. These factors drive up the risk of cancers, diabetes, heart disease, and obesity — all among the top killers in America today.

Our health system came of age when the most pressing health problems people faced were infectious diseases, not these lifestyle-associated conditions. It wasn’t designed to tackle them, and it often doesn’t do a very good job on them. As the lead author on the Oregon study cited above, Katherine Baicker, told me: “There’s lots of evidence throughout the health care system that we don’t do a great job at managing chronic health conditions in general. And Medicaid doesn’t seem like the magic bullet on that.”

3) The studies we have may be too short-term to capture longer-term health benefits. Like many of the papers on the effects of health insurance, the new NBER study had a pretty short follow-up time — two years — and that may not be enough time to detect changes in health status, particularly for chronic conditions like diabetes and cancer. As Benjamin Sommers, a health economist and physician based at Harvard University, put it, “Coverage effects likely grow over time, and while this is a ‘new’ study, it’s not using newer data. It’s still only through the end of 2015, which is similar to what’s already out there.”

4) [This is a condemnation of our health system] Health insurance isn’t the same as access to care, Kosali Simon, who has also studied the impact of insurance on health, told me. “[This is] because of the hurdles in navigating the health care system, or finding the best providers, or adhering to medical advice, and all the other factors that go into meaningful health improvements.” Those are conditions that one’s insurance status won’t necessarily ameliorate — which also means health professionals need to find ways to make insurance a more powerful tool to improve health.

5) There may be limitations to the methods used to study health improvements with insurance. Many of the studies on the impact of health insurance rely on self-reported data (how people think about their health status) or administrative data (like medical claims to track costs and what services the newly insured might be using). But these methods may not be the best ways to measure health.

Her even-numbered theories support Ross Douthat’s theory that most Americans are irrational to buy health insurance because it doesn’t do any good, but that is such a severe condemnation of the health industry representing about 1/6th of the US economy, that it is hard to imagine Americans are that irrational.

There are many studies that claim to show that health insurance does not save lives, but they are typically observational studies without any control group or else they have small samples. The Romneycare insurance expansion in Massachusetts was a big expansion and produced one of the best quasi-experimental studies. It found impressive reductions in mortality that the authors attributed to insurance expansion.

On the other hand, Jacob Stegenga, a philosopher from Cambridge University, argues that, “our confidence in the effectiveness of medical interventions should be low” according to former BMJ editor, Richard Smith.  Stegenga bases this on an application of Bayes Theorem:

we should start with a prior belief in the low effectiveness of medical interventions—to the point that “even when presented with evidence for a hypothesis regarding the effectiveness of a medical intervention, we ought to have low confidence in that hypothesis”… empirical evidence to support his particular arguments… Firstly, many medical interventions have been rejected because they don’t work… Secondly, the best evidence shows that many medical interventions are barely effective, if effective at all. Thirdly, there is conflicting evidence on the benefits of many medical interventions.

There is certainly diminishing marginal utility of healthcare and too much healthcare is harmful because it all produces side effects.  I just got the new Shingles vaccine and I was one of the 1/6 of patients (higher in younger people) to get “side effects that prevented them from doing regular activities.  [for] about 2 to 3 days.”  I got them all–I “got a sore arm, …felt tired, had muscle pain, a headache, shivering, fever, stomach pain, [and] nausea.” 

I’m a big supporter of vaccinations, but if this didn’t reduce my risk of shingles by 90%, I wouldn’t be so willing to undergo those side effects.   

Posted in Health

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