Give Me Insurance Or Give Me Death

by Jonathan Cohn | February 16, 2010

Does losing health insurance make you more likely to die? Several years ago, while I was writing my book on health care, I spent a lot of time on that question. I read the two highly publicized reports by the Institute of Medicine (IOM): Care Without Coverage: Too Little, Too Late and Consequences of Unnsurance. I read through the underlying research. And I spoke to as many experts as I could find.

The IOM had concluded that lack of health insurance led to 18,000 deaths a year--a figure that, some experts suggested, was a bit arbitrary. Isolating the effects of uninsurance was just too difficult to arrive at such a specific number. But, plainly, lack of health insurance left people in worse health. Many of them, most likely in the thousands, died every year. The cause-and-effect was certainly consistent with my own observations as a reporter, some of which I'd written about over the years. And so while I didn't make a habit of citing the 18,000 figure, I would (and still do) frequently cite the IOM report, explaining that "thousands" of people die every year because they can't get afford to get recommended medical care.

As you may have heard by now, Megan McArdle has written an article for the Atlantic Monthly questioning that assumption. She's not foreclosing the possibility that uninsurance might make people more likely to die, but she thinks the data hardly support that conclusion. It's not the first time she, or other critics of health care reform, have raised questions about the relationship between health insurance and health outcomes. Since that article's publication, I've been hoping to do what I did a few years ago--sit down with her article, the underlying data, and the compare those with the latest studies on the subject. But I've been too preoccupied with other assignments and tasks.

Ezra Klein, fortunately, has done the due diligence, publishing not one but two lengthy responses to McArdle. He's also posted a guest blog item from the Urban Institute's Stan Dorn, who was the lead researcher on that original IOM study. Austin Frakt has weighed in on this; so has J. Michael McWilliams (guest-posting on Frakt's blog). All of them think McArdle is simply wrong, on the merits. My reading is that they have the better of this argument, by far. But you should read the items, including the rejoinders McArdle posted on her blog, and decide for yourself.

I will, however, add a thought that Klein and other reform advocates (myself included) have made before. Health care reform is not solely, or even primarily, about improving health. It's also about making sure that medical expenses don't ruin individuals and families financially, whether because of a truly catastrophic event that requires intensive hospitalization or a chronic disease that demands ongoing treatment. In other words, it's not just health security that Americans lack. It's economic security. And the one thing we know health care reform will do, even in the heavily compromised version that passed the U.S. Senate, is provide a lot of economic security.

I'm pretty sure McArdle would agree with this, by the way, even if she has other problems with the proposal before Congress. But that's a largely separate debate.

Update: I added the references to Austin Frakt's blog, The Incidental Economist, which I'd read originally but somehow forgot to mention when I initially posted this item.

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