When opinions on health-care insurance stop being polite and start getting complicated
One further comment on the skepticism that some have adopted on whether health insurance coverage saves lives: This is not a skepticism consistent with either their actions or their professed beliefs.
For one thing, all involved have good health-care insurance that is costing them a lot of money. If the benefits of health-care coverage were as unclear as they're suggesting, or if medical care was as dangerous as they're implying, you'd expect to see different behavior. But the skepticism is not even in service of the argument that the affluent and insured should give up their insurance and spend their money on more measurably beneficial goods. It's being applied to health-care reform, which is to say, whether insurance should be extended to people who don't currently have it because they can't afford it.
That's particularly peculiar given that the Rand health-care insurance experiment, which skeptics frequently cite, found that low-income folks benefit the most from health-care insurance. That is to say, the evidence actually suggests that health-care reform makes a lot more sense than, well, the health-care coverage of its skeptics.
Second, the argument that Megan McArdle has previously made against health-care coverage is that cost controls should be avoided because medical innovation is of incredible value. I don't think much of the rigor with which that argument had been made, but put that aside.
What health-care coverage does, in its simplest form, is secure access to medical innovations. To express skepticism about the value of health-care coverage while opposing anything that might reduce the treatments health-care coverage can buy is strange indeed. If the product's value is so unclear even given how much we spend on it, that would strengthen the case for harsh cost controls considerably. Instead, the argument is both that health-care insurance isn't obviously worth it, but that we should also aggressively resist any efforts to cut back on it. There's a lot more respect for the speculative further benefits that insurance can offer the insured than the more measurable benefits insurance can offer the uninsured.
There's also real confusion between whether something is "too small to measure" and whether it's not being measured because we're not cruel enough to run the kind of experiment that would measure it.
The observational studies attempting to control for relevant variables find insurance saves you from death. But if observational studies aren't good enough -- and that's the actual argument of McArdle's piece -- then you've got the studies, some of them natural experiments, that find insurance is very effective at saving you from things that will kill you. In the middle are some studies that are not designed to measure the mortality benefit of insurance, but now they're the studies worth consulting, which is not the position of the people who conduct those studies. (For a more thorough, rigorous look at the research, see this literature review from one of the leading researchers on this topic.)
What we're really left with is a sudden skepticism of health-care coverage being made by people with health-care insurance who believe in medical technology and who are using methodological difficulties to argue against the value of an expansion of health-care insurance to the poor -- who, for that matter, appear to be helped more by health-care insurance than the rich.
I think McArdle, for one, would object to that characterization, and say something along the lines of her point is simply that these are tough questions to answer. I guess they are, but they become very easy to answer when the question is "should I have health-care insurance" or "should I advocate policies ensuring society devote a heavy share of its resources to making sure my health-care insurance can buy me more services in the future." In those cases, the overwhelming bias is towards insurance and its benefits. Things just get weird when we're talking specifically about an expansion of health-care insurance to the poor.
I don't want to be too harsh, and I don't want to imply that anyone is sitting around twirling their mustache thinking up ways to hurt poor people. But opposition to health-care reform (which is different than opposition to the people who would be helped by health-care reform) is leading to some very strange arguments about the worth of health-care insurance -- arguments that don't fit with previous opinions, revealed preferences, or even the evidence the skeptics are citing.
There are methodological questions worth exploring when you're trying to assess the worth of coverage, and though I'll defend my use of the studies that have labored to come to a usable answer on the subject, I think that a fair case can be mounted against the observational studies that best lend themselves to estimating specific death tolls. But the arguments on the table go considerably further than that. Saying that the protective effect of health-care insurance is hard to measure is very different than saying it is "too small to measure," particularly when the comment is coming from someone who pays for health-care insurance, and is being made in context of whether the uninsured should get insurance rather than whether the insured should let go of theirs. There's a methodological question here, and then there are political agendas here, and the two are getting mixed up.
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