Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
Disclosures: Drs. Woolhandler and Himmelstein report serving as an unpaid advisors to Bernie Sanders' presidential campaign and were founders of and remain active in Physicians for a National Health Program, an organization that advocates for single-payer reform. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1403.
Requests for Single Reprints: David U. Himmelstein, MD, 255 West 90th Street, New York, NY 10024; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Woolhandler: 255 West 90th Street, New York, NY 10024.
Dr. Himmelstein: 255 West 90th Street, New York, NY 10024.
Author Contributions: Conception and design: S. Woolhandler, D.U. Himmelstein.
Analysis and interpretation of the data: S. Woolhandler, D.U. Himmelstein.
Drafting of the article: S. Woolhandler, D.U. Himmelstein.
Critical revision for important intellectual content: S. Woolhandler, D.U. Himmelstein.
Final approval of the article: S. Woolhandler, D.U. Himmelstein.
Statistical expertise: S. Woolhandler, D.U. Himmelstein.
Collection and assembly of data: S. Woolhandler, D.U. Himmelstein.
About 28 million Americans are currently uninsured, and millions more could lose coverage under policy reforms proposed in Congress. At the same time, a growing number of policy leaders have called for going beyond the Patient Protection and Affordable Care Act to a single-payer national health insurance system that would cover every American. These policy debates lend particular salience to studies evaluating the health effects of insurance coverage. In 2002, an Institute of Medicine review concluded that lack of insurance increases mortality, but several relevant studies have appeared since that time. This article summarizes current evidence concerning the relationship of insurance and mortality. The evidence strengthens confidence in the Institute of Medicine's conclusion that health insurance saves lives: The odds of dying among the insured relative to the uninsured is 0.71 to 0.97.
Table 1. Summary of Studies on Relationship Between Insurance Coverage and All-Cause Mortality*
Table 2. Why the Causal Relationship of Health Insurance to Mortality Is Hard to Study
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Michael R. Grey, MD, MPH
Saint Francis Hospital and Medical Center
July 10, 2017
Conflict of Interest:
I was an intern in the same program with Dr. Woolhandler was a junior resident and Dr. Himmelstein a faculty member.
A Report from the Committee of Brutal Facts
“If you look for truth, you may find comfort in the end; if you look for comfort you will not get either comfort or truth only soft soap and wishful thinking to begin, and in the end, despair.” C.S. Lewis
Steffie Woolhandler, M.D., M.P.H David U. Himmelstein, M.D.
City University of New York
November 7, 2017
Some health care reforms cost more than expected, others less. Dr. Grey cites the early underestimation of Medicare's costs, but omits cases where costs were overestimated. For instance, the Congressional Budget Office initially projected that the Affordable Care Act's coverage expansion provisions would cost $187 billion in 2017 , its latest estimate is $66 billion lower . Similarly, Medicare's drug benefit has cost 35% less than predicted . Experience in nations with national health insurance (NHI) also indicates that universal, comprehensive coverage need not break the bank. All spend far less than we do, yet avoid the narrow networks and surprise bills that bedevil many patients. Almost all enjoy better health outcomes, and in the ten other countries included in recent surveys, even poor residents reported better access than the average American ; only Germany's primary care doctors were less satisfied than those in the U.S. Nonetheless, Grey is correct that single-payer reform would require tradeoffs. We cannot afford private insurers, who add nothing of value while charging overhead four-fold greater than Medicare's, or the complex payment systems that impose $200 billion in unnecessary paperwork on hospitals and doctors. Nor can we sustain drug firms' exorbitant prices and profits. Our current payment strategies also encourage providers to inflate their billings. Hospitals, HMOs and ACOs live or die based on their bottom line - their profit (or, for non-profits, "surplus"). Profitable institutions can expand and modernize, while unprofitable ones shrivel, even if they're providing excellent and much-needed care. The profit imperative - under both capitated and fee-for-service payment - drives providers to seek out lucrative patients and services, avoid unprofitable ones and portray all patients as sicker than they really are, boosting administrative and total costs..Payment strategies that decouple care from the prospect of profit have proven far less inflationary, and better at matching resources to community need. For instance, Canada and Scotland pay hospitals global operating budgets - like schools or fire departments - obviating the need for per-patient billing. There's little incentive to upcode or cherry-pick, since hospitals can't keep surplus operating funds; new investments are instead funded through separate government grants.Market-driven care is the root cause of America's health care dilemma. No law of nature decrees that costs must soar or patients must suffer; that MBAs should supervise MDs; or that the our nation can't match or exceed others' health care successes. Congressional Budget Office. Letter to Nancy Pelosi. March 20, 2010. Available at: https://www.cbo.gov/sites/default/files/111th-congress-2009-2010/costestimate/amendreconprop.pdf (accessed 10/29/2017). Congressional Budget Office. Federal subsidies under the Affordable Care Act for health insurance coverage related to the expansion of Medicaid and nongroup health insurance: Tables from CBO's January 2017 baseline. Available at: https://www.cbo.gov/sites/default/files/recurringdata/51298-2017-01-healthinsurance.pdf (accessed 10/29/2017). Elmendorf, D. The Accuracy of CBO’s Budget Projections. March 25, 2013. available at: https://www.cbo.gov/publication/44017 (accessed 10/29/2017) Osborn R, Squires D, Doty MM, Sarnak DO, Schneider DC. In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Aff (Milwood) 2016; 35:2327 -2336, The Commonwealth Fund. 2015 International survey of primary care doctors TOPLINE. available at: http://www.commonwealthfund.org/~/media/files/surveys/2015/2015-ihp-survey_topline_11-20-15.pdf (accessed 10/29/2017)).
Woolhandler S, Himmelstein DU. The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?. Ann Intern Med. ;167:424–431. doi: 10.7326/M17-1403
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Published: Ann Intern Med. 2017;167(6):424-431.
Published at www.annals.org on 27 June 2017
Healthcare Delivery and Policy.
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