Our friends on the Progressive left often tell us what a dire catastrophe it is that so many people lack health insurance. Healthcare is expensive. So, the thinking goes, those without health insurance will not seek care when necessary, either because they flat out can't afford it or they are unwilling to pay steep prices out of pocket. Supposedly all this foregone health care leads to bad health outcomes and higher overall mortality.
I have serious doubts about this story. Like I've said many times, the Rand health insurance experiment and the Oregon Medicaid experiment both failed to find any substantial health impact for the "treatment" group. (The treatment group being the group that got into a Medicaid plan in the Oregon experiment and the one that got essentially a zero deductible in the Rand experiment.) And this result is consistent with a lot of observational/regression studies showing the same thing. Put that aside and let's say it's a plausible story that "lack of insurance" -> "less consumption of healthcare" -> "worse health outcomes". (The first causal link is real, but the second is not, assuming the obvious interpretation of the Rand and Oregon experiments is the correct one.)
My question is: Where have these commentators been all year? Consumption of health care is way down, and it's not just nonessential stuff. People aren't just skimping on their annual check-ups. Some people are so afraid of Covid that they're declining to seek treatment for a possible heart attack (which, given enough examples, means some people are not getting treatment for an actual heart attack). There has been a disruption of cancer treatments. People with known cancers haven't been getting their treatments on time, and cancer screenings are way down, which presumably means fewer cancers are getting caught in time to treat them. People are more prone to dither instead of seeking treatment at the first sign of a stroke, which can be deadly. Rapid treatment can spell the difference between life and death for a stroke victim. Patients aren't making it in to see their physicians for prescription renewals that require an office visit. The reduced consumption of medicine is due both to the patients' fear of contracting Covid and initial lockdown orders that put a temporary halt to "discretionary" health services. (Jeff Singer has a useful discussion of the issue here.)
Mental health has taken a serious hit. This is likely more due to the lockdowns themselves than it is a function of disrupted health care, but both effects are in play. Oddly enough, the only "statistically significant" effect of the Oregon Medicaid experiment was the improvement in mental health for the control group, and this was touted as a kind of success. In the Oregon experiment, most of the improvements in mental health happened before there was time for any appreciable amount of health services to be consumed, which probably means the mental health improvements were mainly due to peace of mind about the ability to obtain health care. If that's the case, a lot of people have been living without that peace of mind for much of the past ten months.
My own view is that Progressive commentators on health insurance are wrong about the health consequences of being uninsured. But I also think that the sudden, extreme lack of availability of health services this year has caused real health consequences. You can go to the ER with a heart attack and will receive treatment, insurance or no insurance. But if people are simply declining to go because they've been unduly frightened of Covid (or appropriately frightened, but at the cost of ignoring other hazards to their health), I would expect that to show up in aggregate mortality figures. Much attention has been paid to the excess deaths in 2020, which some are attributing entirely to Covid-19. I think the story will be a little more complicated as this unravels. I would guess that the excess deaths in April and May are primarily due to Covid, but disruption of health services may have become a more important causal factor later in the year. We will know more at the end of 2021, because the CDC publishes its aggregate "cause of death" data at the end of the next year (the Wonder database and the detailed mortality file that I have been analyzing for the past five years). But if your priors are "going without healthcare leads to bad health outcomes", you should be very upset about disruption of services in 2020.
Where is the outrage? I'm sure there has been some commentary on this, and a motivated reader could flood the comments of this blog post with links to news stories. But I've been sampling from the standard news streams. This story should be a major scandal, but it's a barely audible whisper in the cacophony. Nobody wants to say anything that sounds like "We exaggerated the risks of Covid." Suppose we try to deliver a slightly subtle message to the public, such as, "Covid is indeed dangerous, but not enough so that you should ignore the early signs of stroke or heart attack, or forego routine checkups and screenings." I think the narrative crafters, our public health professionals and media folks, are paranoid that this will be heard as "Covid isn't really a big deal," by a news-consuming public that doesn't have any appetite for nuance. They also don't want to put a single arrow into the quivers of conspiracy theorists or malcontents who think that lockdowns are harmful. I think these policy makers and commentators need to contend more seriously with the ways they've been hurting people (even supposing that lockdowns and extreme caution are on net beneficial). To the extent that these are the same people who were telling us how deadly it is to be uninsured, they need to confront an inconsistency in their own thinking.
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