Monday, September 21, 2009

45000 American deaths "associated" with lack of insurance?

The "unbiased" media is currently hyping a Harvard study by David Himmelstein and Dr. Steffie Woolhandler about 45,000 deaths "associated" with lack of medical insurance. The abstract for the study reads in full:
Objectives. A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data.

Methods. We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death.

Results. Among all participants, 3.1% (95% confidence interval [CI]=2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI=1.44, 2.26). After additional adjustmentfor race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance.

Conclusions.Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.

Notice the vagueness of the conclusion: "Uninsurance is associated with mortality." So what does "associated" mean and what kinds of mortality is it associated with? Some mortality is directly connected with medical care (cancer) and some has no connection (car accidents). The abstract gives no indication that an attempt was made to separate out such causes of death. It is not even clear that the subjects were uninsured when medical problems arose, only that they said they were uninsured when first surveyed. Also, what is the "association"? It might be that those who were uninsured when first surveyed are simply people who are lousy at taking care of themselves and who would suffer from increased mortality regardless of insurance status. This is apparently why the study's authors never claim causation between lack of insurance and increased mortality.

CNN is careful to keep the correct wording and never overtly claims causation. (From Madison Park's report, however, a casual reader could easily infer causation.) By contrast with CNN, Air America simply lies:
Study Shows 45,000 Die Every Year Because Of No Health Insurance
By Dan Carter

Proponents of health care reform just got more ammunition in their fight for change. A new study published online today by the American Journal of Public Health claims that 44,789 working-age adults die each year because they lack basic health insurance. [emph. added]

Say Anything blog and Daily Finance both also falsely claim causation instead of mere association.

Incidentally, Dr. Himmelstein, a co-author of this study, is not exactly an unbiased source. He is an advocate of single payer medicine who claims "Single-payer national health insurance could cover the uninsured and upgrade coverage for most Americans without increasing costs."

UPDATE: Megan McArdle discusses recent arguments on this issue.

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