Health Insurance Improves Patients Lives

Originally published 9/21/2017

When I was diagnosed with cancer last year, I was glad that I had good health insurance coverage. I hadn’t realized it at the time, but I now know that I really had nothing to worry about. It turns out that having insurance is not really all that important for our health and well-being. I know this because Congressman Raul Labrador (R-Idaho) told us so. As he put it, “Nobody dies because they don’t have access to health care.” That might be true on some planet, but not on this one. Politifact, which identified a number of studies that showed having health insurance indeed prevents people from dying, later rated this ridiculous claim as “Pants on Fire.”

Rep. Labrador isn’t the only one who thinks that health insurance is of little importance. In a recent opinion piece on Forbes (it’s in the June 29, 2017 issue), I found the following claim from eponymous publisher Steve Forbes (R-Rich Folk), “Shockingly, reputable studies have found no difference in the health outcomes of people on Medicaid and those who have no insurance.” This sentence needs a lot of unpacking, so lets start with his sources. None of the “reputable studies” backing up this claim were cited in his opinion piece, making it difficult to understand what he’s talking about. I guess we should just be thankful that he decided to cite unidentified reputable studies instead of those that are generally held in disrepute. I reached out to Forbes (the magazine, not the man) several time in an effort to track down and read what are undoubtedly some very important studies, but I never got a reply.

I’m guessing that Forbes was referring to this 2013 article published in his own magazine by staffer Avik Roy. The article is about a two-year Oregon study that compared “physical health outcomes” between Portland area patients on Medicaid and those who didn’t have this insurance coverage. The majority of Roy’s article is devoted to explaining why the results obtained in this study wouldn’t be valid (and he’s right) for a wide spectrum of reasons. After doing that, Roy then accepts the overall conclusion of the study, which was that for the few measures that it tracked, there was little overall difference between “outcomes” of the two groups. I found it bizarre that he accepted the studies conclusions after tearing apart the flawed methodology and assumptions under which it was done. Read this opinion piece in the New England Journal of Medicine to gain more insights into the flawed arguments being used by those who don’t think Medicaid improves the health of patients covered by it.

The Oregon study tracked only a very small number of health outcomes in the patients it studied: (1) elevated blood pressure; (2) high cholesterol; (3) elevated HbA1c levels (a test used to diagnose diabetes); and (4) long-term cardiovascular risk, as measured by the Framingham risk score. You don’t have to be a doctor to know that this is a pretty limited set of parameters. It’s not difficult to come up with a list of ailments that most of us would seek medical attention for, but if left untreated, would not affect any of these particular health measures. Here are some examples:

Broken arm

Cataracts

Dislocated shoulder

Hepatitis C viral infection

Facial laceration

Herniated disk

Torn Achilles tendon

Punctured eardrum

Schizophrenia

Parkinson’s

Rotator cuff injury

Rheumatoid arthritis

Macular degeneration

Venereal diseases

Having no insurance would not have changed your “physical health outcomes” as they were defined in this study. Put another way, you can be very sick or injured, but that won’t be reflected in this very limited set of four health measurements. Back in the real world, no one ever asks you about your healthcare outcomes. Instead, your friends will ask you: how are you feeling? And you won’t think about outcomes either. You’ll likely respond with either “I’m feeling pretty good” or “I feel like crap.” I’ll wager that folks without health insurance are more likely to respond with the latter phrase compared to those who are insured.

Few people have a clear understanding of the population that Medicaid provides healthcare benefits to. Who are these poor people? Among its recipients are millions of children with special needs, working-age disabled adults, and elderly folks. Whites make up the largest percentage of recipients (41%), and this group receives nearly 52% of the money spent on the program. A recent report in the Annals of Internal Medicine estimated that for every million people who lose health insurance coverage, about 1,300 people would die prematurely. In the last Republican healthcare plan to be scored by the Congressional Budget Office, the CBO determined that 22 million Americans would lose coverage over 10 years. The current plan being discussed is also likely to take health insurance away from millions of Americans. Not estimated is the amount of suffering that will take place, but won’t be fatal, if millions of people lose their health care coverage.

Mr. Forbes opinion piece was published a few months prior to an article in the New England Journal of Medicine. It’s a review that details just how important health care (including that provided by Medicaid) is to the well-being of people in our country. Dr. Atul Gawande, a co-author of the paper and well-know medical writer and physician, had this to say about its findings, “There is clear evidence that people who get sufficient incremental care enjoy better prevention, earlier diagnosis and management of urgent conditions, better control of chronic illnesses, and longer life spans.” The report ends with the following conclusion: “There remain many unanswered questions about U.S. health insurance policy, including how best to structure coverage to maximize health and value and how much public spending we want to devote to subsidizing coverage for people who can’t afford it. But whether or not enrollees benefit from that coverage is not one of the unanswered questions. Insurance coverage increases access to care and improves a wide range of health outcomes. Arguing that health insurance coverage doesn’t improve health is simply inconsistent with the evidence.”

Then there’s the report prepared by the Institute of Medicine back in 2002 (eight years before the Affordable Care Act (aka Obamacare) went into effect). The IOM, if you didn’t know, is a private, non-profit organization that provides health policy advice. Here’s what they their study (funded by the Robert Wood Johnson Foundation) said about the usefulness of health insurance in the U.S.:

“What difference would health insurance make if the uninsured were provided with coverage? First, they would be likely to use more services like timely preventive care and chronic disease care that match professional guidelines. They would also be more likely to have a regular source of care. Most importantly, if adults were insured on a continuous basis, their health would be expected to be better and their risk of dying prematurely reduced.

The survival benefits derived from insurance coverage, however, can be achieved in full only when health insurance is acquired well before the development of advanced disease. For example, insuring women once cancer is diagnosed will not solve the problem of later diagnosis and higher mortality among uninsured women with breast cancer. Finally, the evidence presented only accounts for some of the advantages that health insurance provides. Financial security and stability, peace of mind, alleviation of pain and suffering, improved physical function, disabilities avoided or delayed, and gains in life expectancy constitute an array of health insurance benefits that accrue to members of our society with health insurance. For many of the 30 million uninsured adults and another 9 million children in America, these benefits remain elusive.”

Health insurance isn’t just about your physical well being. Huge medical bills are the leading cause of personal bankruptcy in the United States. None of the anti-insurance analyses cited by Forbes and other Republicans focus much attention on quality of life issues either. These are every bit as important, and in many cases more so, than actual outcomes. Patients newly diagnosed with terminal diseases, such as ALS or Alzheimer’s, are generally not yet feeling physically terrible when they get the bad news from their doctors. The mental toll that their illness imposes on them at that point, however, is devastating. In 1947 the World Health Organization came up with a definition of the term health: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” We would do well to keep this definition in mind as we debate the value of healthcare in our society. If you want to see just how difficult life can be without insurance, read this account of life in rural Clay County, Georgia to see how the poor get by in a county with only a single healthcare provider. I suggest we try to sign up those who want to take away health insurance coverage through Medicaid to participate in an observational clinical trial. Let’s provide them with the same healthcare options available to the good people of Clay County, and compare their health outcomes with those of a matched population group who do have insurance coverage. I’m sure there’ll be no problem finding volunteers for this study.