How Many People Die From Lack of Health Insurance?

Ultimately, this is the question that needs to be asked. How Many People Die From Lack of Health Insurance? - Megan McArdle - Business - The Atlantic

The left is predictably fond of the study which got the largest number, 45,000 a year. Unfortunately, its authors are political advocates for a single-payer system, who also helped author the notorious studies on medical bankruptcies. Those studies are very shoddily done, with parameters that somehow always conspire to produce the maximum possible number. In the first study, they set an absurdly low threshhold for what constituted a "medical bankruptcy". In the second, they chose 2006, the year after the 2005 bankruptcy reform act had driven an unprecedented spike in filings. It seems pretty likely that medical bankruptcies were bound to be overrepresented in 2006, since most financial events are easier to see coming than illnesses. But even if you disagree--and the authors offered an incredibly wan explanation of why they did--it's very clear that the people who filed in 2006 were not going to be a representative sample of bankruptcies in a normal year. I can't imagine why you would choose to study 2006 unless you were looking for biased results. I have to conclude that their political beliefs are affecting their work, which means I wouldn't touch that 45,000 number with a bargepole--I wouldn't cite anything they authored even if it offered to prove beyond a shadow of a doubt that I was right about everything.

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I'm afraid I'm not confident about any number. All of these studies suffer from unobserved variable bias, which is to say, the uninsured are not like the rest of us. (The long term uninsured, I mean; the short term uninsured are not a large problem for society). There are all sorts of reasons that people end up uninsured, but most of them are correlated with much poorer health outcomes, and only some of them end up recorded in our surveys.

To give you an example of what I mean, one of the two studies that went into the most commonly cited number--the roughly 20,000 a year figure from the Institute of Medicine and the Urban Institute--found that the highest mortality was not associated with being uninsured, but being on a government health care program. (the other excluded those patients). This was true even after they'd run all their controls. Given that the bulk of the coverage expansion in both the Senate and the House plans comes from Medicaid expansion, this is a little disturbing.

But how likely is it that Medicaid is killing people? Possible, I suppose, but not really all that likely. Medicaid and Medicare patients, too, are not like the broader population. The authors in fact recognized this fact in their paper, pointing out that these patients have higher rates of disability--but then failed to address the obvious question this raised about their data on the uninsured.

This problem plagues almost all of the studies on mortality and the uninsured.