[wooter]

"1 in 1000 uninsured people die each year. It's not an exaggeration to say that due to the work we're doing here, 5,000-10,000 people will live to see the end of 2014. You should be proud of what you've done, but we should also all be grateful to have this opportunity."

Hospitals don't let uninsured people die and insuring people doesn't magically save their lives.

[vwinsyee]

> Hospitals don't let uninsured people die and insuring people doesn't magically save their lives.

Not sure where you're getting this. A quick Google Scholar or PubMed search shows a consensus that mortality rate is significantly higher for uninsured than for insured. [1, 2, 3]

[1] e.g. http://jpubhealth.oxfordjournals.org/content/32/2/236.short -- On multivariate analysis, uninsured compared with insured patients had an increased mortality risk (odds ratio: 1.60, 95% CI: 1.45–1.76). The excess mortality in uninsured children in the US was 37.8%, or 16 787, of the 38 649 deaths over the 18 period of the study. Children who were hospitalized without insurance have significantly increased all-cause in-hospital mortality as compared with children who present with insurance.

[2] e.g. http://journals.lww.com/jtrauma/Abstract/2012/11000/Undiagno... -- Undiagnosed preexisting comorbidities play a crucial role in determining outcomes following trauma. Diagnosis of medical comorbidities may be a marker of access to health care and may be associated with treatment, which may explain the gap in mortality rates between insured and uninsured trauma patients.

[3] e.g. https://www.sciencedirect.com/science/article/pii/S000296101... -- A total of 1,203,243 patients were analyzed, with a mortality rate of 3.7%. The death rate was significantly higher in penetrating trauma patients versus blunt trauma patients (7.9% vs 3.0%; P < .001), and higher in the uninsured (5.3% vs 3.2%; P < .001). On multivariate analysis, uninsured patients had an increased odds of death than insured patients, in both penetrating and blunt trauma patients.

[trhway]

>mortality rate is significantly higher for uninsured than for insured.

correlation doesn't mean causation.

>to help make our government work better

i somehow doubt that throwing a team of "rockstars" to clean up the mess is making the government to work better. If anything, it enables the typical government behavior we saw in the case of healthcare.gov.

[vwinsyee]

> correlation doesn't mean causation.

As a statistician, I guess I should be happy that more people are aware of this. But I also think too many people are taking "correlation != causation" superficially. I mean, almost all of science is based on significant correlational findings, especially when the traditional way to prove causation (i.e. via randomized trial) is unethical (i.e. we can't randomly assign people to be insured vs. uninsured).

Along these lines, I often find people who say "correlation != causation" don't stop and wonder "so how _can_ we prove causation (in a non-randomized study)?" I guess many of them can be partially excused since the answer is non-trivial. But generally, here's a few rules of thumb for making a stronger case for causality from correlation:

* the effect size is relatively large (e.g. uninsured children die at 60% higher odds than insured children)

* the cause comes before the effect (e.g. people are uninsured before they go to the hospital and/or die)

* reversible association (e.g. risk of dying at a hospital changes when people get insurance)

* consistency / consensus across multiple studies (e.g. many studies showing that a difference in insurance status is associated with a significant difference in hospital mortality )

* dose-response relationship (e.g. I didn't link examples previously -- but there were a few studies showing that different levels of insurance, from none to Medicaid to private, is associated with different rates of hospital mortality)

* plausibility (e.g. even from a qualitative point of view, it's quite believable that people who unable to pay a hospital bill might get worse service)

[DanielRibeiro]

Please turn this into a blog post and submit it to HN. I'd love to see this comment about correlations see more attention ;)

[Fomite]

I just submitted this: https://news.ycombinator.com/item?id=7317254 which is the CrossValidated (StackOverflow for stats) discussion of whether or not causation implies correlation.

[gizmo686]

All good points, but you also should consider the plausibility of it being a correlation. By this I mean that there seem to be clear candidates for a common cause between no insurance and high mortality, for example: income.

Once you control for this, and other potential common causes, your case for causality becomes much stronger (or non-existent).

[Fomite]

If you had read the paper linked above, you'd note they controlled for income.

[aero142]

Many people believe that the Oregon Health Study is the best chance we have of teasing causation out of the data. It is still in progress but it is being watched closely. http://oregonhealthstudy.org/

[tunesmith]

To clarify, this is because they actually did what would normally be unethical: they randomly assigned citizens to be eligible for the insurance plan. It was a lottery.

[anon808]

so are you saying not having health insurance is better for people? I'll take the common sense angle that having health insurance increases the chances of medical care being applied to a health problem, versus not having any health care insurance.

there's no such thing as a monolithic 'government' being that can either work better or be enabled to act a certain way. there are people, and groups of people that do certain things. some of those things are worthless, some of those things are worthwhile. i'd argue the mess the 'rock stars' cleaned up is a generally positive activity.

[trhway]

>so are you saying not having health insurance is better for people?

i'm just saying that being from a poor or damaged family, uneducated, having mental illness or substance abuse problem, etc... usually leads to higher mortality and also to not having health insurance. Giving them a health insurance [i'm all for it, i think modern civilized society should provide basic level of free health insurance to everybody] would be inconsequential in many cases as not having the insurance isn't the cause, just a manifestation.

>there's no such thing as a monolithic 'government' being that can either work better or be enabled to act a certain way.

http://en.wikipedia.org/wiki/Systems_theory

and if we specifically consider a closed loop system of "government + society" then this may be of interest too:

http://en.wikipedia.org/wiki/Cybernetics

[saraid216]

I completely support the conclusion that we should be fixing our third variables.

[Crito]

Hospitals do "let" uninsured people die because they are not obligated to provide the full extent of their care capabilities to people who cannot afford it. Come in with a hole in your abdomen, and for sure they'll patch you up even if you don't have insurance. Come in riddled with cancer? Don't expect the same as they would give somebody who could pay themselves or had insurance.

This said, it is still a shoddy use of statistics. "1 in 1000 uninsured people die each year" by itself tells us pretty much nothing. What is the rate of death for insured people?

Wikipedia tells me that 8.39 in 1000 people die in America every year, so if uninsured people are only dying at a rate of 1 in 1000 every year, it seems to me that either it is beneficial to be uninsured, or uninsured people are not representative of the population (perhaps because many of them are young and healthy?).

I suspect that what is going on is this person actually meant to say something along the lines of "1 in 1000 people die every year in ways that could have been prevented if they had insurance" A subtle but important difference. The actual mortality rate of uninsured people is most likely much higher than 1 in 1000, but the deaths of uninsured people in motorcycle accidents would not be counted in that "1 in 1000" figure.

Either way, it is shoddy.

[brandonb]

Yes, I meant to say 1 in 1000 uninsured people die each year in ways that could be prevented by insurance coverage. Here's an article that references a few of the reports: http://www.reuters.com/article/2012/06/20/us-usa-healthcare-...

[twistedpair]

> Come in riddled with cancer? Don't expect the same as they would give somebody who could pay themselves or had insurance.

Ah, yes, the classic American healthcare problem. The poor person just gets to go to hospice and keel over. The rich person gets to limp along, endure 3 rounds of chemo, and spend the few remaining months of her life hooked up to machines in what is arguably a Pyrrhic victory and even lower quality of life.

[Crito]

You know that many people actually survive cancer and go on to live otherwise regular lives, right?

[arrrg]

Many people survive cancer or can at least add many years to their life with relatively high quality of life.

Many others don’t survive, obviously, but the chance of survival of many cancers really isn’t so bad.

[twistedpair]

Thx. Spent years working in oncology, so I'm quite familiar that people can survive. My point is that American medicine is insanely expensive because we don't know where to draw the line. Now, more than before, we focus on anything to keep the heart beating and the lawyers from suing, regardless of whether the quality of life and and dignity of the patient is non-existent.

Given this, I would argue the "poor person" in this argument could easily get similar levels of necessary care as the insured individual through Medicare. The insured (preferably rich) person could however travel to all the best clinics, participate in many medical trials and experimental operations, and quite likely simply spend their final months of life as a guinea pig with a similar outcome as the "poor person." The only upside is the insured individual gets to bankrupt themselves and family in the process as insurance doesn't cover most of these non-standard therapies. I've seen it happen to too many people.

[akiselev]

Yes because chemo is the first thing we give to people with malignant cancers.

[jbooth]

Hospitals don't turn away uninsured at the ER.

However, due to lack of regular care, by the time you show up at the ER it might be too late.

[beat]

I have high blood pressure. Thanks to insurance, I was able to spend a few months with my doctor, experimenting with medications until we found the combination that brought it down to manageable levels. Meds cost me $15 a month or so.

Blood pressure medication will almost certainly add many years to my life - decades, maybe. Without insurance, I couldn't have afforded the half-dozen trips to the doctor or the meds. And I'd wind up getting lifesaving treatment for an early heart attack or stroke in the ER.

I'll take the insurance, thanks.

[liber8]

Honest, non-snarky question for you: How is it that you could not afford a half-dozen trips to your doctor, but you could afford your medical insurance premiums? Are your premiums subsidized or free? Is the doctor terribly expensive?

(I'm assuming that your doctor charges $250 or less per visit. Six visits would cost $1,500. I'm assuming those visits were spread over at least a number of months, so you could see whether each medication was effective. I'll also assume your health insurance is at least $400/month, though that number is likely higher if you're over 30 or female. This means your six visits cost roughly four months worth of insurance premiums.)

[beat]

Honest, non-snarky answer... to be pedantic, for me it's not a question of affordability. I'm a software professional with a very good income, and I could do it on my own.

I have a friend a few months younger than me. She makes less than $15k/year, and has two children living at home. Under those financial circumstances, she has totally paid off her home, which should tell you how frugal and responsible she is. She has also experienced extensive hospitalization due to illness. If she had to pay for that (it was paid for by state-subsidized health care), she'd have lost her house.

edit: Medical costs are the leading cause of bankruptcy in the US.

[hga]

"Medical costs are the leading cause of bankruptcy in the US."

In a study by Elizabeth Warren that scored any bankruptcy which included medical bills in the discharged debts as their "being the cause" of it, no matter what the fraction they were.

[mikeyouse]

That's dramatically misrepresenting the quality of the study;

http://www.businessweek.com/bwdaily/dnflash/content/jun2009/...

[jdminhbg]

> Without insurance, I couldn't have afforded the half-dozen trips to the doctor or the meds.

> Honest, non-snarky answer... to be pedantic, for me it's not a question of affordability.

This is a pretty good representation of the quality of health care discussion on HN.

[jrockway]

He misspelled one word. s/couldn't/mightn't/.

[ansible]

I'm assuming that your doctor charges $250 or less per visit.

Well, that just a visit. What about lab tests? Doctor offices can do some basic stuff in-house, but for anything interesting, it has to be sent to an external lab. Depending on the tests, that could be $500 USD a pop, easy.

And the medication is expensive too. That drug may be costing the patient $15 per refill, but it definitely costs more than that in total.

[protomyth]

"Without insurance, I couldn't have afforded the half-dozen trips to the doctor or the meds."

This is actually the problem for a large group of insured. It would be cheaper to pay out of a health saving account and have catastrophic insurance than pay the continuing insurance premium. This is especially true for young workers who we are now forcing into an additional cost to support older workers. For the price you were paying for insurance, the health saving account and paying out of pocket for those exams would have been cheaper. People unable to pay that should have been the ones helped by a health care law, not the typical consumer.

If we would get rid of this "one size" crap and deal with the groups we actually have (e.g. "ongoing expensive care", "typical person", "catastrophic"), we would have had a much better system. Grand visions suck for normal people.

[beat]

The problem with that is that the people with the highest medical costs (the elderly) are retired and no longer generating income to pay for their care. Gotta pay for that somehow. The whole point of insurance is to distribute costs.

[rdl]

The elderly (>65, or >62 in some cases, etc.) are already covered by medicare and social security. The disabled were covered by medicaid and ssi.

Underemployed (part time, whatever) or sort-of-poor and not disabled people in their 50s are a major segment who can't pay the real cost of their medical care, though. Or, people with lifelong expensive illnesses in the 0-64 age range (who are often making a lot less money than median, too, due to their medical conditions.)

[protomyth]

Medicare does a good job with hospital visits but has some serious holes in the drug buying.

Those in their 50's should have had some cash built up from earlier savings, but they spent it all on premiums instead of building up a hedge. Lifelong illnesses are something that we should just acknowledge as bad for insurance and deal with otherwise. Insurance should be for events and not continuous medical conditions.

We have not dealt with the price of medical care in a sane manner. I don't think the political will exists to break the current insurance scheme while at the same time not overreaching with government.

[protomyth]

An expansion of social security / medicare (particularly if they were paying into a health savings account throughout their low risk period) to cover drugs and such would have been quite a bit cheaper. The youth already are paying for the elderly with taxes, we shouldn't run a con job on them too.

The concept of insurance we use for healthcare is broken.

[dragonwriter]

> An expansion of social security / medicare (particularly if they were paying into a health savings account throughout their low risk period) to cover drugs and such would have been quite a bit cheaper.

You act as if an expansion of Medicare to cover prescription drugs was an alternative to the more recent reforms, rather something that already happened prior to them and did not, as you suggest, address the problem that the more recent reforms were aimed at.

[dragonwriter]

> Hospitals don't let uninsured people die

They don't do as much to stop them from dying. (Other than public hospitals -- of which there are a limited number with limited capacity -- they are only obligated to stabilize them in the ER and then, if they have further medically-necessary care but are stable, they can discharge them and/or transfer them to a public hospital if one is available, whereas those that have resources, insurance or otherwise, to pay would be admitted.)

> insuring people doesn't magically save their lives.

Strictly true -- it doesn't do so magically. It does so, instead, but the relatively mundane mechanism of providing them the ability to pay for care other than emergency stabilization, which reduces the probability of them having such care denied or delayed.

[brandonb]

An estimated 26,000 people die each year due to lack of insurance coverage. That's part of the reason the Affordable Care Act was passed. For more information, see this Reuters article from 2012:

http://www.reuters.com/article/2012/06/20/us-usa-healthcare-...

[at-fates-hands]

Too bad the people who actually need it, are not signing up. Not to mention the people who HAD coverage are now getting cut off of their insurance and forced into the exchanges. A complete failure anyway you look at it.

http://www.forbes.com/sites/theapothecary/2014/01/18/coverag...

"Instead of expanding coverage to those without it, Obamacare is replacing the pre-existing market for private insurance. Surveys from insurers and other industry players indicate that as few as 11 percent of those on Obamacare’s exchanges were previously uninsured"

But wait a minute! Obamacare was supposed to cut my rates my $2,500 A YEAR right? WRONG. Apparently, it still costs too much for the people who really need it:

"Of those that didn’t sign up for Obamacare-based coverage, 52 percent stated that “affordability” was their biggest complaint with the exchanges’ plan offerings. Only 30 percent cited “technical challenges in buying the plans.”

"Joan Budden, chief marketing officer at Priority Health, told Wilde and Mathews that Michigan’s health insurers had expected 400,000 uninsured Michiganders to enroll in exchange based plans during the initial enrollment year. According to the latest data from the Obama administration, as of December 28, only 75,511 had “selected a marketplace plan.” Of those, only an unknown fraction had paid their first month’s premium, and therefore were actually enrolled in new health coverage."

So if this is such a success, why isn't the White House trumpeting the real numbers of people who've signed up then??

http://www.washingtontimes.com/news/2013/oct/4/white-house-s...

"For the fourth day in a row, the Obama administration on Friday declined to release figures on how many Americans have purchased health insurance through the just-opened online markets tied to the new health care law.

White House spokesman Jay Carney told reporters that millions of people have visited the federal HealthCare.gov site, which directs people to coverage options, but he did not have “specific data” at this early stage in the enrollment period."

There are better ways to do this than handing over 1/3 of our economy over to the Federal Government. You want competition? You can start by letting insurance companies deal across state lines. More competition, increased quality of care, lower costs and better care for everyone.

[3am]

Did you read the links in your post? The first doesn't strongly support your points, and the second was out of date almost 4 months ago.

And that's really saying something, because the first link is an OpEd by Mitt Romney's former health care advisor who is a senior fellow at a conservative think-tank.

Some of the downsides of allowing health insurance to be sold across state lines are addressed at http://www.kaiserhealthnews.org/stories/2010/september/30/se... - and they include an AEI fellow's views for balance. The auto insurance market is a hybrid, though, and doesn't show a large cost savings for states that effectively allow cross-state lines operations via identical regulations.

I think it's also fair to ask also why health insurers that operate in all/most states (UnitedHealth, Aetna, Cigna, Athena, etc) are not substantially cheaper that BC/BS peers that don't.

[JPKab]

My mother in law has worked for the past 15 years at jobs which employ her for 39.5 hours a week and don't give her health insurance. She suffers arthritis in her hands and knees. She signed up and received health insurance for the first time in 15 years last week. She is now receiving the medical care she needs. Had she not, she would have had to apply for disability benefits. Now, she gets to keep working.

You don't know what you are talking about. My mother-in-law makes shit money, and yet she has a plan that is extremely affordable for her.

Your a partisan hack, and your facts are regurgitated from professional partisan hacks. Your absurd "handing a 1/3 of our economy over to the Federal Govt" comment points out your biased sources of knowledge. How is a website which matches consumers with private insurance companies equate to "handing over" to the Federal Government? What planet do you live on? Alabama?

[AutoCorrect]

anecdotal evidence and ad hominem attacks don't help you argue your points.

[JPKab]

Agreed. But partisan hackery is like porn. You know it when you see it.

[runamok]

They don't let them die right there because of the Emergency Medical Treatment and Active Labor Act (EMTALA). But they patch them up and send them home as soon as they're stable. That absolutely leads to significantly worse outcomes which others have referenced.

http://en.wikipedia.org/wiki/EMTALA

[untog]

People have to be inside hospitals for hospitals to help them. If you don't have insurance you're less likely to go in the first place.

[ryanhuff]

I question the validity of your statement. In the US, for many uninsured, the hospital ER is their primary care outlet.

[untog]

But by the time they go to the ER it's too late. People with insurance go for regular checkups that will catch things early. Those without will only go to the ER when their situation is desperate.

[ryanhuff]

Perhaps you misunderstood my comment. Many uninsured in the US go to the hospital ER for minor care, such as for colds and other temporarily ailments. I suspect that these sort of cases far outnumber the visits involving serious care cases.

[Shivetya]

you would be surprised how many with insurance don't go or don't listen to their doctor. it has nothing to do with insurance and more to do with fear or just laziness

[kyro]

You're talking about EMTALA, which is an act that prohibits turning away uninsured patients away who are in need of emergent care. Once the patient is stabilized and either discharged or admitted, they are subject to payments.

The patient with metastatic cancer who needs chemoradiation on an outpatient basis must pay for his/her care.

[dragonwriter]

> You're talking about EMTALA, which is an act that prohibits turning away uninsured patients away who are in need of emergent care. Once the patient is stabilized and either discharged or admitted, they are subject to payments.

More importantly, as it only requires emergency stabilization and not further care to be provided without regard to ability to pay, once they are stabilized they can be discharged instead of being admitted.

[PhasmaFelis]

> Hospitals don't let uninsured people die

Irrelevant, even if true. Uninsured people often don't go to the hospital until it's too late, because they know the expense will ruin them and they're hoping it will get better on its own.

[kevincrane]

But if you know you can't afford it, maybe you'd avoid going to the hospital when you really should.