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Are Deaths Due to Lack of Health Insurance Seriously Underestimated?

letsgetitdone's picture

Lately, I've had the feeling that “progressive” journalists and commentators too often pull their punches in calling attention to social problems, by underestimating the magnitude of problem-related statistics such as the unemployment rate and the number of fatalities due to lack of health insurance in the United States. My theory about this is that “progressives” are being defensive in their approach and bending over backwards to give the right wing the benefit of the doubt by understating numbers out of an abundance of caution.

If this is right, then my reply is that underestimating problem-related numbers is just as bad as over-estimating them, and that what people ought to do is try to provide the best estimates they can and let the critical chips fall where they may. In this post, I want to raise a question about the accuracy of the numerical estimates of US deaths due to lack of health insurance often seen in articles and blogs authored by people, like myself, who favor eliminating insurance coverage shortfalls by passing Medicare for All.

The Woolhandler/Harvard Study and Its headline Finding

When progressives write about the number of deaths associated with lack of health insurance they, almost invariably, directly cite or project from the headline finding of an analysis of data, gathered by the Third National Health and Nutrition Examination Survey (NHANES III), done at the Harvard Medical School whose results were published in the American Journal of Public Health in December of 2009, with pre-publication prints appearing at least as early as September of 2009. The peer-reviewed article reporting the results of the study directed by Steffie Woolhandler, was co-authored by Andrew P. Wilper, MD, MPH, Steffie Woolhandler, MD, MPH, Karen E. Lasser, MD, MPH, but pre-publication Danny McCormick, MD, MPH, David H. Bor, MD,and David U. Himmelstein, MD.

The NHANES III survey data was gathered over the period 1988 – 1994, and followup interviews were then conducted in the year 2000. The Harvard researchers analyzed the data using a Cox Regression proportional hazards model, a method widely used in medical research and epidemiology. They calculated “hazard ratios” from the data using this modeling and analysis method and then went on to calculate propensity scores, and finally used those to estimate fatalities among the uninsured using Census data.

The article reporting their study was frequently cited in the run-up to passage of the Affordable Care Act (ACA) in the Fall of 2009 - 2010, and its headline conclusion has been cited ever since in articles and blog posts much too numerous to cite. The headline conclusion, as normally stated is that there are 44,789 or sometimes approximately 45,000 fatalities annually associated with, or more boldly, caused, by lack of health insurance.

In the Wilper et al article however, the headline finding stated is (p. 2292):

Replicating the methods of the IOM panel with updated census data24,25 and this hazard ratio, we calculated 27424 deaths among Americans aged 25 to 64 years in 2000 associated with lack of health insurance. Applying this hazard ratio to census data from 200526 and including all persons aged 18 to 64 years yields an estimated 35327 deaths annually among the nonelderly associated with lack of health insurance. When we repeated this approach without age stratification, (thought by investigators at the Urban Institute to be an overly conservative approach)23 we calculated approximately 44789 deaths among Americans aged 18 to 64 years in 2005 associated with lack of health insurance.

IOM in the above quote is the Institute of Medicine of the National Academy of Sciences, and the citations in the above passage are to Centers for Disease Control and Prevention, National Center for Health Statistics, Census Bureau, and Urban Institute Reports. Note that the number of deaths estimate applies to the population 18 – 64 years for the year 2005. There's no claim in the above quote that the same estimate would apply to the years since that time or to the whole population under 65. But on p. 2294, in the conclusions section, the authors say:

Lack of health insurance is associated with as many as 44789 deaths per year in the United States, . . .

This is clearly an overdrawn conclusion since it's dependent on the 1) estimated hazard ratio remaining constant, 2) estimated base populations of both insured and uninsured remaining the same when these are changing every year, and 3) extent to which the various limitations they mention on pp. 2293 - 2294 of their article lead to an underestimate of the hazard associated with being uninsured. The likelihood of these limitations leading to an underestimate of deaths in their study is very great, as the authors themselves say.

So, given this, why say: “. . . as many as 44789 deaths . . . “ above. Why not say “. . . . at least 44,789 deaths in 2005 and most likely substantially more than that . .. “? And why not also point out that since in the years after 2005 the number of uninsured has increased compared to 2005, and that the deaths have also increased, even assuming that the hazard ratio has remained the same, and hasn't gotten worse?

A Question About the Study and Two Error Scenarios

But beyond this, the article by the Harvard researchers raises a question that, depending on the answer, suggests an error that, in turn, suggests they may have provided a substantial underestimate of the number of annual fatalities even based on the data. In the quote from p. 2292, the 44,789 deaths associated with lack of health insurance in 2005 are assigned to the 18 – 64 population, not the whole population under 65.

This statement may be an error of reference. The authors may have meant to say that this was the total for the under 65 population; or alternatively they may have stated their finding accurately. Their conclusion doesn't shed light on this ambiguity, because it doesn't mention the 18 – 64 age group. The New York Times article announcing release of the study quotes or paraphrases Dr. Steffie Woolhandler liberally, but uses only the “ . . . 45,000 deaths a year in the United States, . . .” without qualification by age group. Every other citation of the study I've seen since its release does the same, in plain contradiction with what the quote from p. 2292 states. So, which is it, an error of reference, or a more substantive error in not estimating deaths for the under 18 age group and adding them to the total?

Table One: Estimates of Population and Fatalities 2005 – 2012 Due to Lack of Insurance Under the Two Harvard Study Error Scenarios

Table One: Estimates of Population and Fatalities 2005 – 2012 Due to Lack of Insurance

Table One does a few things. First, it reports the most current Census Bureau population and uninsured population numbers for 2005 – 2012. Second, it provides estimates of deaths associated with lack of insurance from 2005 - 2012, assuming that the Harvard study made a misstatement in reporting that its deaths number of 44,789 applied to the 18 – 64 group, rather than to everyone under 65, as is implied by its conclusion. My estimates used the ratio of the 2005 death estimate to the uninsured estimate of 43,035,000 which is .0010407, and projected it to the years 2006 – 2012.

In effect, I'm assuming that the hazard ratio, on which the 2005 estimate is based, is constant over the period 2005 - 2012. It may not be, but I know of no data to the contrary. So, until there's new data I think that assumption is the best one we can make.

Third, Table One also provides death estimates for the 2005 – 2012 period assuming that the deaths reported do apply to the 18 – 64 population and that this number needed to be supplemented by estimating 2005 deaths based on the population under 65 including children under 18 as well as the relatively small population over 65 that is uninsured (presumably people who have not enrolled in Medicare or any other insurance plan).

The Census Bureau report linked to above, estimates total uninsured in 2005 at 43,035,000, and uninsured children under 18 at 7,636,000. So, the total number of uninsured excluding the children is 35,399,000. It also turns out that there are 424,000 uninsured over 65. So, the uninsured population in the 18 – 64 group is estimated at 34,975,000, and this is the number of insured on which the estimate 44,789 is based, if the report of results as stated on p. 2292 is NOT in error.

The ratio of the death estimate to the uninsured population estimate in the 18 – 64 group is 44,789 to 34,975,000, or .0012806. Applying that ratio to the population of uninsured given by the census data for 2005 – 2012 gives the death estimates in the rightmost column of Table One. Again the underlying assumption is that the hazard ratio is constant over time.

Conclusions

So, which of the two errors was made in the Harvard Study has differing implications for estimates of deaths due to lack of insurance progressives that should be citing from the years 2005 – 2012. The second error scenario in Table One, if true, shows a much more serious underestimate of likely mortality than the first, but even the first error scenario involves a substantial underestimate of the deaths due to lack of insurance over the eight years from 2005 – 2012. Specifically, the assumption that deaths have averaged 45,000 per year and totaled 360,000 over the period, leads to a result that estimates 27,801 deaths less than can be reasonably projected. What reason is there for putting this kind of shortfall forward?

In the Harvard Study, the authors mention various limitations of the study. The limitations collectively suggest that the 44,789 estimate is itself a substantial underestimate of the reality. So what sense does it make to understate the problem of deaths due to lack of insurance further by continuing to cite the 2005 result without trying to update it for the increases in the number of uninsured that have occurred after 2005? It just gives away unnecessary ground to those who want to maintain the status quo and leave us with the fatalities their indifference to the problem is creating.

So, what am I saying? If you're going to cite estimates of death due to lack of insurance, then please update them for changes in the size of the uninsured population before tossing them off.

And what if the second error scenario is true? Then the problem of under-estimation is still more serious, specifically the under-estimate under this scenario is 117,174, or an average of 14,647 per year, an under-estimate of the seriousness of the problem by more than 30%. If the second error really occurred in the Harvard study, then this degree of under-estimation is a lost opportunity to make the opponents of Medicare for All, including both those who want no Government in health insurance at all, and supporters of the ACA face the consequences of their actions.

Since 2010, those consequences have included anywhere from approximately 150,000 to 187,000 fatalities due to lack of health insurance. That's unconscionable and immoral, especially because there was another choice, a road we failed to take. Let's hope we can get on that road again rather than having to wait for it to be blindingly obvious that beyond all the spin, a neoliberal, market-placed based system of health insurance, can only lead to injustice, more death and misery for many Americans.

(Cross-posted from New Economic Perspectives)

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Submitted by Hugh on

Thanks. I like this post because it reminds me of what I do when I analyze jobs and employment. Understanding the numbers depends on understanding the definitions as well as the way they were calculated, because the difference between what people assume is being measured and what is, in fact, being measured can be quite large.

There are other questions that could be asked along this line as well. For example, how many of the uninsured have suffered moderate to severe long term medical consequences from being uninsured?

How much increased mortality and morbidity have there been among the underinsured, as compared to the insured population? How do we define "underinsured"?

And how many of the uninsured and insured will move into the underinsured category under Obamacare, and what will be their expected levels of mortality and morbidity?

How will any changes to Medicare and/or Social Security affect the mortality and morbidity of those over 65?

For some of these questions, we could at least begin the process of answering them. For others, like cuts to Social Security, they are important to keep in mind as we go forward.

Hugh

Submitted by Hugh on

A further thought, there are already comparisons out between the US healthcare system and others in the industrialized world. I am, in particular, thinking of Australia which has a good single payer plan and a similar lifestyle to the US. And of course, there is Canada right across the border. Now while I have seen rankings and longevity comparisons, I have never seen any calculations of how much mortality and morbidity the US system is costing us. It would seem to me that these would be quite feasible to do. You could age stratify these as well. Indeed I wonder if any such studies have already been done, and I have not heard of them. Failing that, I wonder why they have not been done. It is an important question. How many people are dying and getting or staying sick, who don't need to, because of the American corporate approach to medicine.

Hugh

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Submitted by Cujo359 on

Which provides an example of what I'm talking about. Even if you compare the US's preventable mortality rate with the next-worst on the list (the UK) and assume a population of 310 million in 2011, that means we lost about 40k more people than we should have. Even the least bad number is a lot of people.

Submitted by hipparchia on

adding to the commonwealth fund study, we were already in last place by 2002-2003

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aicuTZz3sykc

uninsured adults nearing medicare age use more medical care once they turn 65

http://www.nejm.org/doi/full/10.1056/NEJMsa067712?hits=10&andorexactfull...

but have improved (self-reported) health once medicare is taking care of them

http://jama.jamanetwork.com/article.aspx?articleid=209868

still, we're behind other countries even then (scroll down to the two figures at the bottom of the post)

http://theincidentaleconomist.com/wordpress/how-flawed-is-life-expectancy/

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Submitted by Cujo359 on

While I agree we should try to be as accurate as possible, 45k deaths a year is a dreadful number already. That's far more than die by homicide and traffic accidents combined. Saying it's like a 9/11 every month, which I've done on occasion, understates how bad that number is, yet when you put it that way it points out our priorities. Sometimes, it's less about the numbers than the idea. That may be why some commentators understate these numbers - the understated ones ought to be bad enough already.

Thanks for looking into this, though. Like Hugh says, what the numbers mean and what we think they mean based on news or blog reports can often be quite different.

letsgetitdone's picture
Submitted by letsgetitdone on

are terrible enough. But, evidently not to conservatives. I'm not sure that increasing them by 30% will be any more impressive to them. But we won't know that until we try to tell the terrible truth rather than carelessly using the under-estimates out of some concern about being wrong because our estimates are too high. We're not loan officers wanting to make conservative loans after all. We're people trying to get recognition for a social problem. Again, we shouldn't be pulling any punches because we're trying to protect ourselves.

Cujo359's picture
Submitted by Cujo359 on

If it were an order of magnitude greater, it might change some thinking. Just being a little bigger isn't likely to change anyone's opinion. In some cases, it's not going to matter what that number is until it's clear they or the people they care about could be among them. Accuracy is best, and to me deliberate exaggeration buys you nothing if in the long run it's clear you're wildly wrong. I know I have an abiding disrespect for arguments where dangers are exaggerated in order to scare me. I don't know how common that feeling is, but I'm pretty sure I'm not alone.

letsgetitdone's picture
Submitted by letsgetitdone on

That's why I don't like the 45,000 figure. It may have been the best one in 2005. But never after that, as I think I've shown.

Dromaius's picture
Submitted by Dromaius on

Is that they equate deaths to lack of health "insurance," which implies that health insurance means health CARE.

The reason for the deaths is lack of health CARE. Health insurance is not the same thing as health CARE, especially not the high deductible junk that we have now. It can actually be an impediment to care, when people pay for premiums, then no longer have dollars to see a doctor.

Lacking health insurance is a symptom, not a cause.

Submitted by lambert on

Frame it as lack of insurance is the problem, and the solution will be to get people insurance. Back to square one.

First they ignore you, then they ridicule you, then they fight you, then you win. -- Mahatma Gandhi

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Submitted by letsgetitdone on

the two. You have to understand the proportional hazards model. It doesn't say there's no death among the Insured for any number of reasons. What they're saying is that the state of not being insured is associated with 45,000 more deaths annually than the alternative.