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The 150,000-life health-care plan

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By now, you're probably used to hearing about the $900 billion health-care bill. But what about the 150,000-life health-care bill?

Oddly, that label hasn't made its way into the conversation. But it is, if anything, a conservative estimate. The Institute of Medicine developed a detailed methodology for projecting the lives lost due to lack of insurance. The original paper estimated that 18,000 lives were lost in 2000, and the Urban Institute updated that analysis with data for 2006, yielding an estimate of 22,000 lives. As for 150,000, well, that's almost certainly too low. That's just the 2006 number across 10 years, which is the time frame we generally use for health care, with a third of the lives saved lopped off, as we're not going to cover all of the uninsured. But since the population of the uninsured grows every year, and so does the death toll, it would surely be higher. So call it the 150,000-plus-life health-care plan.

We're very comfortable talking about the financial cost of health-care reform. We're less comfortable talking about the human benefits. But the fact that health insurance saves lives isn't controversial. A 2003 study examining cancer records from Kentucky found that uninsured women with breast cancer were 44 percent likelier to die than their insured counterparts. And that was after controlling for demographics, stage of diagnosis and initial treatment. A 2007 study found that the uninsured were 24 percent to 56 percent likelier to die of stroke, depending on the type. That study, too, controlled for all the relevant variables. Other studies have examined the issue more generally, using all manner of data sets and controlling all manner of variables. The Urban Institute's report summarizes a number of the papers.

All this is intuitive. The uninsured are less likely to seek early care. They are less likely to get good care. They are less likely to return for follow-up care. They are less likely to be able to afford the maintenance of chronic conditions. At its most basic level, that's what this is all about. That's why people have been fighting for universal health care for almost a century now. That's why this matters, and why the basics of the bill -- subsidized access to health-care insurance -- are so terribly important. This is life and, well, death. Lots of it, in fact.

But we don't like to talk about it that way. Occasionally, people justify this methodologically: It's too hard, they say, to know exactly how many people die because they don't have access to health insurance. But projecting the cost of the bill is no easier, or more certain, and yet we use those numbers with impunity.

In reality, people don't like to talk about health-care reform in terms of lives because it seems, on some level, unfair. It sounds almost like an accusation of murder. That's common rhetoric when talking about wars but not social policy.

But it isn't an accusation of murder. It's a statement of benefits. And there are iterations in which the costs could outweigh the benefits: The money could do much more good elsewhere, say, or the regulations would thoroughly impede medical innovation. That's an argument worth having, but it should be had. As it is, we talk about the costs in very specific terms and the benefits in very abstract terms. That biases the discussion toward the opposition and against, well, the 150,000 or so people whose lives would be saved by by this bill.

Which is a bit strange, in the scheme of things. Medicare saved lives. Medicaid saved lives. The health-care coverage that costs the average worker more than $13,000 saves lives. That's why we shoulder these expenses. And health-care reform will save lives, too. That's why we're doing it. That's why we're thinking of spending $900 billion on it. And those who would be so cavalier as to close the door because of the public option, or the Medicare buy-in, or the absence of either thing, should think long and hard about those numbers.

I could imagine a cost-benefit analysis that judges the whole bill worth it, or the whole bill not worth it. But it is very, very hard to imagine a cost-benefit analysis in which small policies operating on the margins and promising to save small-but-measurable amounts of money are worth more, in either direction, than the hundreds of thousands of people who will be saved -- not to mention spared bankruptcy, and lifted from chronic pain or impairment -- by the rest of the bill. The areas of controversy have become very slight given the magnitude of the underlying bill.

By Ezra Klein  |  December 14, 2009; 9:25 AM ET
Categories:  Health Reform  
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Next: Think Tank: The cost of being uninsured, how to boost employment and more

Comments

Why no mention of this? http://www.harvardscience.harvard.edu/medicine-health/articles/new-study-finds-45000-deaths-annually-linked-lack-health-coverage

Posted by: emmas | December 14, 2009 9:39 AM | Report abuse

In your earlier post about Lieberman, you clearly and plainly linked his political decision to killing people. That is despicable. Klein, you are no different than the pro-lifers who accuse MDs of killing children by performing abortions. The same fanatic hatred drives you both.

Posted by: WashingtonDame | December 14, 2009 9:39 AM | Report abuse

WashingtonDame

lieberman's actions are despicable.
joe lieberman's political actions will kill people.

on this holiday of eating latkes, and celebrating a festival of light and illumination and gladness, lieberman has forgotten the most sacred principle of his faith....tikkun olam.
to leave the world a better place than one finds it . to help to heal and alleviate the suffering of others.
joe lieberman needs to live the principles and most sacred beliefs of his faith.
it is a sadness to see a man who professes piety, turn his back on the sufferings of millions of people.
it sets a bad example and is karmically wrong.
by working for the good and highest principles, he could affect the lives of millions with the power he has....instead, he has coldly turned his back on millions of suffering of people, and he has desecrated the principle of tikkun olam.

Posted by: jkaren | December 14, 2009 9:54 AM | Report abuse

"pro-lifers who accuse MDs of killing children by performing abortions."

doctors do not kill "children" when performing an abortion...but denying health care to a sick person, who may very well kill them.
your analogy is incorrect.

Posted by: jkaren | December 14, 2009 10:04 AM | Report abuse

I just don't understand how Lieberman can justify his position. Obviously, he's never spent a minute in his life thinking about what things would be like if he didn't have health insurance. Obviously, he's never been seriously, chronically, ill.

Imagine being in your 40's. Imagine having a disease that, untreated, would probably cripple you within a couple of years. Imagine that treatment costs somewhere north of $20,000 a year.

Now think about how that scenario changes the choices you make. Thinking about starting a business? Sorry, that's not an option you can pursue. Small business owners with pre-existing conditions can't buy health insurance. Want to go back to school? Same story. No, the only choice you can make is to work for an employer, the larger the better (larger generally = better coverage) until you're 65 -- you need the insurance.

Do you want to be that person? What happens if you get laid off? Even if you're able to afford COBRA, what happens if you don't manage to land a corporate job within 18 months? Can you imagine the desperation that begins to tinge your job search around month 12 as you're staring down the possibility of losing coverage for the drugs that allow you to function? Can you imagine knowing that a few months without the expensive drugs you need could result in crippling, permanent damage to your joints?

Obviously, Joe Lieberman can't imagine any of those things.

Posted by: jaye_eldridge | December 14, 2009 10:10 AM | Report abuse

Ezra,


How many doctors will stop accepting Medicare patients if its opened up to the 55-64 crowd assuming docs are paid at medicare rates especially in rural areas or where the population is older? And when/if docs stop accepting Medicare patients how many people will die from that? This is something that gets very little attention. From what I see many docs are at the brink of not accepting Medicare due to low reimbursements and that may push many over the edge. Maybe 10 years from now we can have a study on that.

Posted by: visionbrkr | December 14, 2009 10:30 AM | Report abuse

It's the new paradigm: The poly-sci, green eye-shaded twit can proscribe the citizenry's freedom if the amount of other people's money doesn't seem to him too large an amount to spend.

You're measuring other people's lives with coffee spoons, Klein, and you should be ashamed.

Posted by: msoja | December 14, 2009 10:39 AM | Report abuse

The estimate of benefits must, like that of costs, look to the future. A first approximation: 22k deaths a year for the next 50 years comes to 1.1 million early deaths averted. Discount at 5% for uncertainty - not intrinsic time preference - and you have a present-value equivalent of 400,000.

Now to do this seriously, you should take quality-adjusted life years (even the best-treated Americans will die someday), factor in the trend in population, and allow for the rising proportion of uninsured as the existing "system" continues to unravel, etc. But you already have an order of magnitude.

Posted by: JamesWimberley | December 14, 2009 10:49 AM | Report abuse

Now here's the other thing. In general, people are willing to pay somewhere between $1M and $5M to avoid an unnecessary death, or in compensation for one. So using your (relatively conservative, working-adult-only) figures, that's an avoided cost to the economy of $20-100 billion a year over the life of the bill.

Posted by: paul314 | December 14, 2009 10:56 AM | Report abuse

Ezra, I had to return and comment again after reading your post down page about Leiberman.

I am still really shocked that you have droppped down to the Daily Kos/FDL level with your "analysis". If you're concern is really about getting people covered, than you need to be just as critical to the left who is opposing any legislation that does not include an expansion of gov't insurance programs (Medicare and/or Public Option).

Just because Leiberman thinks exanding Medicare to 55-64 is a bad idea, does not equate to him wanting to kill thousands.

Anything less is hypocritical.

Posted by: truth5 | December 14, 2009 11:00 AM | Report abuse

This is very interesting, not because of your claims about lack of insurance killing people, but because it indicates desperation.

Are progressives who will only vote for reform if it includes a public plan or early Medicare buy-in killing people? Or is it just Joe Lieberman who is killing people?

This hysterical line of argument is an early sign that HC reform is dead.

Posted by: MBP2 | December 14, 2009 11:09 AM | Report abuse

Sorry, Ezra, but morality only has to do with sex. Opposing homosexuality and female sexual activity is how we decide what's moral and pro-family. So providing health care that saves 150,000 lives really doesn't have anything to do with anything.

Signed,
The Republican Party and the United States Conference of Catholic Bishops.

Posted by: eelvisberg | December 14, 2009 11:10 AM | Report abuse

This is just ridiculous on so many levels.

Plenty of reasonable people have good reason to believe this bill will make our health care system worse, not better, which would mean even more deaths in the future.

People will still die due to lack of healthcare under this bill. Why aren't you lambasting the Democrats for not spending even more money? This arbitrary $900B is not nearly enough, why do you want thousands of people to die Ezra?

Every one of those people could have received the care they needed if the doctors and hospitals would have provided it despite their inability to pay. Aren't they even more to blame then Joe Lieberman? After all, they hold the power to save lives in their hands, and have refused to use it tens of thousands of times every year.

Please, stop stooping to the level of the most ill-informed and reactionary left-wing bloggers. This tactic is beneath you.

Posted by: ab13 | December 14, 2009 11:14 AM | Report abuse

and for chrissakes jkaren, please stop torturing all of us with the kumbaya greeting card pablum.

Posted by: ab13 | December 14, 2009 11:16 AM | Report abuse

Man, I just don't understand people. Ezra's post about Lieberman below is at worst vaguely worded. "Cause" could certainly mean "kill" in the way some people here are taking it, but it can also mean that his opposition to a healthcare bill will lead to the bill failing, which will lead to people dying. Fortunately, in this post Ezra clarified his position. Even if Ezra may have written the last post while angry and perhaps intended to imply the first possible meaning, we're on the internet, people. A charitable reading of this blog takes his most recent clarification as his intended meaning.

So, Ezra's saying that Leiberman is opposing small slivers of this bill which are essential to getting liberal senators on board. This is compromise legislation and it has been from the beginning. Liberals aren't getting what they wanted, and conservatives won't either. But Leiberman is taking his objection to a relatively small part of the bill and taking to the point of potentially killing reform altogether. This will lead to thousands of people dying.

Ezra's point is that we're comfortable talking about opposition to proposed bills saving the country money, or stopping more regulation which may or may not have a negative effect on the economy. We're not, however, comfortable talking about opposition to a proposed bill meaning that the people who would have been helped by the bill not receiving that help. In this case, failure to pass a bill will allow more people to die unnecessarily.

Leiberman is opposing this legislation for no obvious policy reasons, since every reason he's stated has been false. He's made himself the lynchpin to this whole bill. It's perfectly appropriate to ask him why it's worth it for all these people to die in order to stop a relatively small expansion of government involvement in healthcare.

Posted by: MosBen | December 14, 2009 11:25 AM | Report abuse

Also, we as a people make value judgements based on lives all the time. Outlawing motorcycles would save some number of lives, but we don't do it because we deem the loss of those lives to be outweighed by the benefit of people being free to make the choice to ride a motorcycle if they so choose. I don't drive a motorcycle, but I'm comfortable with the lives lost in exchange for that freedom until someone makes a convincing argument otherwise.

We always govern based on a calculus of lives. It's not an accusation of murder.

Posted by: MosBen | December 14, 2009 11:28 AM | Report abuse

Thanks, Ezra, for reminding us what health care reform is all about. After this is all over, someone will write an updated edition of "Profiles in Courage", describing those in Congress who did the right thing. At this point, Lieberman only qualifies for a "profile in peevishness".

Posted by: BillKramer1 | December 14, 2009 11:30 AM | Report abuse

ab13, Ezra is not accusing Leiberman of killing these people. He's not saying it's murder. He's not even saying Leiberman has ill intent for opposing healthcare. He's saying that Leiberman's stated reasons for opposition have no basis in fact and it's becoming more and more likely that the reason really is just something petty.

Ezra (and I, and most liberals) would love to ditch the arbitrary $900b figure. You're right; it's stupid and means we get incomplete/worse reform. But this is the number that the majority has agreed on. This bill is imperfect. People will still die unnecessarily if it passes, and that's horrible, but people will also be saved and more people will die in the bill's absence. It's not a perfect bill, but it's a bill that has the support of the majority of senators. The area of debate has narrowed to such a ridiculous degree that barring some really good argument, which Leiberman doesn't have, it's insane to filibuster a bill that will save so many people based on such narrow disagreement.

Leiberman (or you) may say that the disagreement may be narrow, but he *really* cares about it. Well, losing the Medicare expansion loses more votes than it picks up (and that's assuming that Leiberman would actually acquiece if he got his way), so it's really just one man standing in the way of the bill passing. He needs to be asked, and it's fair to do so, if he cares about his opposition to this narrow issue more than he cares about the number of lives the rest of the bill will save.

Posted by: MosBen | December 14, 2009 11:36 AM | Report abuse

MosBen, whether or not Lieberman has a principled or factual reason for opposing this bill (I don't particularly like the guy and have no desire to defend him), what you and Ezra are completely ignoring is that a lot of us think this is a terrible bill that will make our health care system worse, not better, and does nothing to rein in costs, which should be the primary goal. So framing it as saving X number of lives in the short term is meaningless. Are those 150K lives worth more than the lives that will be lost in the inferior (inferior compared to a better bill, not compared to the status quo) health care system that would result from this bill? You and Ezra are acting as if it's this particular reform or nothing, and if that is the case that's the fault of the Democrats, not the fault of Joe Lieberman or anyone else who opposes this bill.

Posted by: ab13 | December 14, 2009 11:48 AM | Report abuse

First, I'll just say that those small bits at the margins have a lot to say about quality of actual health services provided AND about the power and money that will be available to health insurance companies to wield in Washington.

I'd also like to point out the omission of quality of life. It may be most obvious in your statement about uninsured breast cancer survivors having a 44% greater likelihood of death than those with insurance. Omitted is the probability that given uninsured breast cancer what is the probability that a mastectomy saves their life? And how does this compare to the insured breast cancer survivor?

People need to quit telling themselves that we have always had poor people and there's nothing to be done about it. That's why people except this unnecessary tragedy. The Republicans spend all their time trying to convince people that the tools and knowledge we have doesn't exist or won't work.

This entry sort of fits with Uwe Reinhardt's recent blog entry where he asks if Americans are less generous than Europeans:
http://economix.blogs.nytimes.com/2009/12/11/on-health-care-are-europeans-just-kinder-people/

Posted by: bcbulger | December 14, 2009 11:50 AM | Report abuse

ab13, but Ezra said (and again I agree with him) that it's perfectly legitimate to disagree with the bill as a whole. You can argue that the bill as a whole doesn't do enough to reign in costs, or doesn't improve healthcare, or whatever. That's fine, but it's stacked in opposition to the lives the bill will save and we shouldn't be squeemish about making that calculus. As I said, we've decided that it's worth it to have X number of people die per year so that motorcycles can be legal. Some may argue that it's not worth it, some may argue that it is, and disagreement is ok but we shouldn't pretend that we're not talking about human lives here.

We do it all the time with wars. This war is worth the loss of life while another isn't, but policy can affect lives as well.

Again, debate is fine. If you think there's more to be lost here then gained then make the argument. Leiberman's made his arguments based on things that simply aren't true, so it's his false arguments stacked against the lives the bill will save. It's fair to ask him why he thinks it's worth it, particularly since his false arguments are pretty exclusively to a minor subset of the bill.

Opposition is fine. Disagreement is fine. But we shouldn't pretend this is all abstract, except when it comes to money.

Posted by: MosBen | December 14, 2009 11:56 AM | Report abuse

MosBen, I can't speak for Lieberman's motivation. Maybe he's a sadistic a-hole who wants people to die. Maybe he realizes how much power he holds over this process and loves it. Or maybe he just thinks this is a bad bill and is willing to be dishonest and disingenuous to kill it.

"Opposition is fine. Disagreement is fine. But we shouldn't pretend this is all abstract, except when it comes to money."

I don't think anyone is doing that. Ezra is presenting a false choice between this particular bill and 150K deaths. Not only are there more alternatives than that, it ignores the fact that the 150K number is meaningless without a comparison. How many people will die under the substandard system we end up with? How many people die in other countries due to (prohibitively expensive, and not very cost effective) treatments that we use and they don't? The 150K number also assumes that we can expand the same level of coverage we have now to everyone without any reduction in quality or outcomes.

Another thought, most of the provisions in the bill don't even start for a few more years. Why are Ezra and the Democrats willing to let 15K people die every year until then instead of starting everything right away? Could it be because they do not think the cost is worth it? How is that any better than what Lieberman is doing?

Posted by: ab13 | December 14, 2009 12:23 PM | Report abuse

"Just because Leiberman thinks exanding Medicare to 55-64 is a bad idea, does not equate to him wanting to kill thousands. "

No.
But he's willing to kill thousands to stop it.

Posted by: adamiani | December 14, 2009 12:49 PM | Report abuse

I wish there are similar studies that will highllite the number of lives that will be lost as a result of Obamacare's negative effects on the overall healthcare system in the US. My guess is, more people will die as a result of inferior quality and quantity of coverage.

Besides, why doesn't mr Klein talk about people in Africa who are dieing everyday in thousands because of lack of food/water. While you are at it, why not talk about the whole world? Is the life of a poor boy dieing in Africa any less valuable than those so called 45 millions (or is it 13 or 15?) uninsured?

Homocrats cite number and studies when it supports their agenda! So much for having a "world view"!

Posted by: darkskin1977 | December 14, 2009 1:00 PM | Report abuse

Yeah right, cut medicare and insure the illegals. Of course, seniors' lives are much more expendable than younger unisured voters!

It's all about vote bank politics, I have lived in third world democracies long enough to see vote bank politics being played in the name of the "common good"! WTF!

Posted by: darkskin1977 | December 14, 2009 1:04 PM | Report abuse

Going off of paul314's logic, 150,000 lives times $5 million per life (a common statistical value of a life) is $750 billion. This is surprisingly close to the actual extra expenditures from the bill of around $900b.

Posted by: hsjcoan1 | December 14, 2009 1:38 PM | Report abuse

Let me get this straight:

Ezra pointing out that at least 150,000 people will die without medical coverage over the next few years - COMPLETELY OUTRAGEOUS AND OUT OF BOUNDS

Sarah Palin and Republicans claiming that fictional government Death Panels will kill senior citizens and sick people to save money - Reasonable debate that the media should take seriously.

Posted by: lol-lol | December 15, 2009 10:34 AM | Report abuse

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