[HN Gopher] An accidental experiment that saved 700 lives ___________________________________________________________________ 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 It was a feature of | Obamacare which was later repealed.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. ___________________________________________________________________ (page generated 2022-04-15 23:00 UTC)