[HN Gopher] An accidental experiment that saved 700 lives
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An accidental experiment that saved 700 lives
Author : luu
Score : 62 points
Date : 2022-04-13 23:06 UTC (1 days ago)
(HTM) web link (statmodeling.stat.columbia.edu)
(TXT) w3m dump (statmodeling.stat.columbia.edu)
| johnorourke wrote:
| It's so very weird reading this as a UK citizen. It feels like
| reading about some kind of dystopian future. Despite the UK
| government's best efforts to the contrary, even the poorest in
| society can still access health care locally at no cost... except
| the hospital car parking fees, that's a killer.
| [deleted]
| zeristor wrote:
| Not everyone has a car.
| Beltalowda wrote:
| Most (all?) hospitals are easily reachable by public
| transport. I've never had a car and never had trouble getting
| to a hospital when needed.
| analog31 wrote:
| I got a ride to the hospital.
|
| The ambulance ride cost me $2000 out of pocket.
| throw10920 wrote:
| > Inside was a letter stating that they had recently paid a fine
| for not carrying health insurance
|
| What? The IRS can _fine_ you for not having _health insurance?_
| dahfizz wrote:
| Yes, it was called the Individual Mandate. It was a feature of
| Obamacare which was later repealed.
|
| https://www.healthinsurance.org/glossary/individual-mandate/
| vinyl7 wrote:
| California has a fine for not having health insurance.
| dudeinjapan wrote:
| Or, the accident that killed 700 people? I guess I'm a glass
| half-empty kinda fella.
| [deleted]
| [deleted]
| DoreenMichele wrote:
| Obamacare was likely the only politically viable solution at the
| time. I wish we would use it as a stepping stone to more
| comprehensive coverage for all US residents.
| darkerside wrote:
| In retrospect, Obama seems to have made a terrible mistake with
| the Obamacare framework. He made the original sin of
| acquiescing that there would be no single payer, thereby
| relinquishing his only true leverage over an obstinate Senate
| clinging to a skin Democratic majority.
|
| The compromise was not a good one. It never made great sense
| for any of the parties. It was a victory of pragmatism over
| function, and no Republican voted for it anyway.
| DoreenMichele wrote:
| And yet now this _accidental experiment_ exists because of
| Obamacare which settles a longstanding debate in the US as to
| whether healthcare coverage actually saves lives -- while
| Europeans go "Well, duh? Why was this ever a question?"
| robocat wrote:
| From paper: "Of the 4.5 million households who met the criteria
| for inclusion in this pilot program, 3.9 million were randomly
| selected to receive the intervention.", "The final sample
| consists of 4.5 million returns, corresponding to 8.9 million
| individuals."
|
| Those in the treatment group were 1.3[1] percentage points more
| likely to enroll in coverage in the year following the
| intervention than those in the control group: about 50,000 extra
| households (~100,000 extra people) were signed up due to the
| letter.
|
| So, about 200 died because they didn't receive the letter (But
| that was offset by the 8 billion lives that were saved by
| something else that didn't happen that day.).
|
| [1] "those in the treatment group were 1.3 percentage points more
| likely to enroll in coverage in the year following the
| intervention than those in the control group, a 2.8% relative
| increase. On average, each letter increased coverage among this
| group by 0.14 months during 2017, or one additional year of
| coverage per 87 letters sent. We document larger effects among
| individuals who lacked any coverage during the prior year and
| among older non- elderly adults."
|
| Edited: corrected numbers - mistook households for individuals.
| hackernewds wrote:
| Not to be a nihilist, but 200 seems like a ridiculously and
| surprisingly low number for impact of such an expensive and
| broad program. Does it really validate what the author posits?
| lavishlatern wrote:
| Bear in mind nearly all of the people receiving letters
| should be <65. I quickly skimmed the paper and it seems like
| the authors don't have enough data to come up with a quality
| adjusted life-year type of statistic like the NHS uses.
| robocat wrote:
| On second thoughts, that should be 100: I stuffed up mixing
| households versus individuals.
|
| "The final sample consists of 4.5 million returns,
| corresponding to 8.9 million individuals. Individuals in the
| sample were randomly assigned to receive a letter (86%) or to
| a control group (14%). One letter, addressed to the
| taxpayer(s), was sent per return. Hence, randomization was
| conducted at the household level."
|
| So 86% of 4.5 million households were sent a letter, and that
| led to a 1.3% percentage point increase in signups compared
| to the 14% of households that were not sent a letter. They
| are then saying that those 1.3% of extra signups led to
| saving ~700 lives. There is the risk of a selection bias
| because we don't know why those extra 1.3% signed up versus
| those that didn't.
|
| The actual paper uses months, since everyone dies, so zero
| lives can be saved in the long term.
| LorenPechtel wrote:
| Note that only those influenced to buy insurance would show
| any possible benefit.
| Johnny555 wrote:
| _At the end of 2017, Congress passed legislation eliminating the
| health law's fines for not carrying health insurance, a change
| that probably guarantees that the I.R.S. letters will remain a
| one-time experiment._
|
| I still get a form from my employer proving that I had health
| insurance, so even with a financial penalty there's no reason
| that the letters can't continue to be sent out to the uninsured
| to remind them of options.
| anm89 wrote:
| > The experiment, made possible by an accident of budgeting, is
| the first rigorous experiment to find that health coverage leads
| to fewer deaths,
|
| It, of course, does not prove this. It proves that within this
| specific set of circumstances, within the specifics of our
| current health care system, that increasing coverage lead to
| fewer deaths. You can't just automatically extrapolate that to
| health coverage in general.
| actually_a_dog wrote:
| And there exists at least one field in Scotland in which there
| exists at least one sheep, at least one side of which is black.
|
| Look, this was literally a randomized controlled study of the
| entire US population. You know, the gold standard for
| generalizability. And what other point of comparison would
| possibly be relevant besides "the specifics of our current
| health care system?" What more do you want?
| windows2020 wrote:
| So, 0.0002% of the population, ignoring that the 1.2% who
| received a letter may have different risk factors. Sorry, not
| interested in mandated health care (or any unauthorized Federal
| mandate). And there is no such thing as 'free healthcare.'
| metacritic12 wrote:
| The pilot was randomized.
| mint2 wrote:
| Don't wear seatbelts either huh?
| tantalor wrote:
| > made possible by an accident of budgeting
|
| Would this have been legal/ethical to do intentionally?
| gumby wrote:
| Probably not, because how would you get consent from the test
| subjects without messing up the test?
| mbac32768 wrote:
| As a counterpoint, the Oregon Medicaid health experiment was also
| an RCT but found the opposite.
|
| https://en.wikipedia.org/wiki/Oregon_Medicaid_health_experim...
|
| > Approximately two years after the lottery, researchers found
| that Medicaid had no statistically significant impact on physical
| health measures, but "it did increase use of health care
| services, raise rates of diabetes detection and management, lower
| rates of depression, and reduce financial strain."
| PaulHoule wrote:
| The point of the individual mandate was never that it was good
| for the individuals, but rather that it avoids 'adverse
| selection' where healthy people see the price and decide they
| can't afford it but the mom with MS who has a kid with spinal
| deformation thinks 'what a bargain!'
| paxys wrote:
| A person who thinks they are healthy but goes for an annual
| checkup just because it is covered by insurance is still
| benefiting from this.
| someguydave wrote:
| unless they get unnecessary treatment and/or unneeded
| testing.
| dwighttk wrote:
| Ha... I'd love a plan that covered an annual checkup. Never
| seen one of those as an option.
| paxys wrote:
| All health plans in the USA must fully cover an annual
| physical and other preventative services (like shots and
| some kinds of screenings) under the ACA.
| hibikir wrote:
| They do, but beware fun fees: I've spent hours of my life
| disputing a psych evaluation charge (under 5 minutes of a
| pediatrician asking a kid how they are feeling, without
| any paternal prompting), which the insurance company
| claimed it wasn't covered in the free physical. So you go
| to a supposedly fully covered appointment, and come back
| home to a bill you have to pay, or argue with.
| maxerickson wrote:
| It's not just the insurance company in that case though,
| the doctor's office would have submitted an additional
| billing code for the appointment (which for something
| like you describe should probably be treated as fraud).
| darkerside wrote:
| The original idea with insurance providers was that they
| were more educated than their customers, and since they
| were paying, they would be incentivized and better
| capable of negotiating with medical providers.
|
| Of course, this has proven not to be the case. Part of
| the reason is that insurance providers are legally
| prohibited from making profits beyond a certain
| proportion to what they actually pay for medical
| services. So now, they are actually incentivized for
| _higher_ medical costs.
| dwighttk wrote:
| From hhs.gov:
|
| >Most plans must over [sic] a set of preventive services
| - like shots and screenings - at no cost to you.
|
| >For example, depending on your age, you may have access
| to no-cost preventive services such as:
|
| And goes on to list many things but not an annual check
| up. And also notice "most", "depending on your age", and
| "may".
| paxys wrote:
| So if you schedule a visit to a doctor without a specific
| problem and they give you your yearly shots and do
| routine tests, and all of that is covered by insurance,
| what do you call it?
| dwighttk wrote:
| A plan I'd like to have offered to me.
| wtallis wrote:
| > And also notice "most", "depending on your age", and
| "may".
|
| You say that like you think those are being used as
| weasel words. But they're just allowing for a more
| concise summary that does not need to recite every nuance
| of the requirements, which rightfully are not written as
| one size fits all. Factors like your age truly do matter
| to the question of what preventive care makes sense, and
| it would be a bad public policy to require insurers to
| cover care as preventive in situations where it does not
| have preventive value.
| LorenPechtel wrote:
| Other than as part of an overall plan what would be the
| point? The cost would be the cost of an annual checkup.
| Other than if you could pay it with pre-tax dollars what
| would be the point? Insurance is about risk, not about
| certainty.
| bbarnett wrote:
| Weird! So many things cost less, if caught early. A _lot_
| less.
| dwighttk wrote:
| Hey I'm on the same page. Doesn't make any sense to me.
| jimmaswell wrote:
| Has this been happening now that it was eliminated? Costs seem
| the same as before for me.
| ceejayoz wrote:
| My premiums went up 10% this year, to over $2,400/month for
| the family.
| labster wrote:
| That's normal inflation for health care.
| [deleted]
| phnofive wrote:
| This is the same argument for any tax. Tollbooths, for example,
| have quantifiable deficiencies, but feel more fair... to some.
| drc500free wrote:
| In the long run, it's trying to avoid the adverse selection
| death spiral where the price keeps rising to match the costs,
| and squeezing more people out of the pool.
| dahfizz wrote:
| Was this ever a real problem, before or now after the
| individual mandate?
| BurningFrog wrote:
| Before Obamacare adverse selection was managed by the
| "preexisting condition" system.
|
| Much like how you can't sign up for fire insurance when your
| house is already burning, you couldn't get insurance only
| after you need care.
|
| Obamacare did away with "preexisting condition", and the
| mandate was meant to replace it.
|
| With nothing at all acting as a backstop, AFAIK, I assume
| this is now baked into the ever exploding "cost disease" of
| US health care.
| anamax wrote:
| > Obamacare did away with "preexisting condition", and the
| mandate was meant to replace it.
|
| The Obamacare "fix" already existed in several states. You
| believe that such a policy has certain consequence - can
| you identify those states by looking for that consequence?
|
| Note that pretty much every state had "if you keep your
| care, you can change", so the problem was only for folks
| who left and wanted back in.
|
| If you have a relevant condition, leaving seems like an odd
| thing to do.
| LorenPechtel wrote:
| Some states had high risk pools. Limited coverage,
| limited access, high premiums.
| actually_a_dog wrote:
| That's some serious twisting of words to claim that
| straight up denying people health insurance is "managing"
| anything.
| _jal wrote:
| "Empirical evidence of adverse selection is mixed. Several
| studies investigating correlations between risk and insurance
| purchase have failed to show the predicted positive
| correlation for life insurance, auto insurance, and health
| insurance. On the other hand, "positive" test results for
| adverse selection have been reported in health insurance,
| long-term care insurance, and annuity markets."
|
| https://en.wikipedia.org/wiki/Adverse_selection
| LorenPechtel wrote:
| It used to be that if you had health issues you simply
| couldn't buy insurance, period. My former employer failed in
| the housing collapse, trying to get private "Please feel free
| to reapply when you have a diagnosis." I'd love to have even
| a real diagnosis, but I do not expect I ever will.
| knorker wrote:
| > the first rigorous experiment to find that health coverage
| leads to fewer deaths, a claim that politicians and economists
| have fiercely debated in recent years
|
| Living in Europe I must have missed this debate. Is it not self-
| evidently true? What are the arguments against it?
| BurningFrog wrote:
| Most studies on the topic shows that having health insurance in
| the US doesn't impact people's health much or at all.
|
| Everyone agrees this is counterintuitive, but that's been the
| data so far. This study adds some weight to the other side.
| autoexec wrote:
| > Most studies on the topic shows that having health
| insurance in the US doesn't impact people's health much or at
| all.
|
| I can't speak to "most" having not seen all of them, but
| studies have shown it matters.
|
| https://www.theguardian.com/us-news/2017/jun/24/us-
| healthcar...
|
| These came up a year later:
|
| https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323087/
|
| https://news.gallup.com/poll/268094/millions-lost-someone-
| co...
|
| Seems there has been some prior evidence for supporting the
| idea that health insurance (the only way to get affordable
| healthcare in the US) matters.
|
| What are examples of studies that show it has little to no
| impact?
| ahupp wrote:
| In the US you still get emergency medical care without
| insurance but then have to deal with the bill. Sometimes that
| means bankruptcy, sometimes its forgiven. The elderly (65+)
| have universal care through the government account for most
| mortality.
|
| So with those combined, it means the impact of coverage on
| mortality is small enough that its hard to measure. Of course
| avoiding financial catastrophe is also a good reason for some
| kind of universal coverage even if the direct health benefits
| are low.
| knorker wrote:
| Right, but none of the two methods you mention will get you
| treatment for any cancer your get in your 40s, right?
|
| Is the argument that before 65 people just don't die from
| anything medical, except things emergency room will treat?
|
| But then there's also the secondary effects, like losing your
| house because of medical bills. And we know that even with
| universal health care (every civilized country except the US)
| health is associated with money.
|
| Another reply asserted that studies say it doesn't help much,
| but... that's just so counter intuitive to me that the the
| studies that were replied there saying actually it does help
| can be summarized by "well, duh".
|
| But I've thought "well, duh" about false things in the past,
| which is why I want to know.
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