As I continue to prepare my upcoming series on health insurance, a recent article in perhaps the most respected medical journal in the world—the New England Journal of Medicine—sheds some light on one of the fundamental questions that underpins the entire concept of health insurance, which is: Does having health insurance actually make a difference in people’s health outcomes, including mortality? After all, if having health insurance really doesn't make a difference in how people fare after they get it, then the intense ongoing debate about the insurance market becomes largely irrelevant.
The article, “Health Insurance Coverage and Health — What the Recent Evidence Tells Us,” co-authored by noted Harvard surgeon and writer Atul Gawande, MD, MPH, is a scholarly analysis of the available data on the impact of health insurance on health outcomes. The article’s bottom line, to use a phrase the authors themselves use, is that any conclusion drawn on this subject must be nuanced. They conclude that health insurance does indeed produce positive health outcomes, but with qualifications. One of the problems in any such analysis is the relatively short-term nature of the available outcome data, during which time any health outcomes might be quite modest; many health effects, especially those that are preventive, take place over long periods of time. In my own field of cardiology, for example, we know without question that treating high blood pressure is beneficial, but the greatest effects are seen after years and even decades of treatment. A study that looked only at the six-month or one-year impact of treating high blood pressure might well find muted or no effects—despite the positive impact one sees after long-term treatment.
With that important proviso in mind, Dr. Gawande and his co-authors (all from Harvard) conclude that their analysis of the available data shows that obtaining health insurance improves the financial security of those gaining insurance (naturally enough) and reduces their anxiety regarding financial matters. Gaining health insurance also improves patients’ access to care and the use of preventive health services, which, over time, should eventually result in better health outcomes. And, the authors conclude, most available data indicate that people gaining health insurance experience an improved sense of well-being and self-reported health.
The data are much less clear as to whether people not only feel better but actually are better, the authors note. And as to the biggest question of all – does health insurance reduce mortality? – the authors give a nuanced answer, which I would characterize as “maybe.” The authors reference one study, for example, that suggested that if one gave 830 previously uninsured adults insurance coverage, then one life might be saved over the subsequent year. But other data they reference show no clear positive impact on subsequent mortality.
Finally, the authors emphasize that whatever benefits may follow expanding health insurance coverage come at a substantial financial cost to society and the economy.
That probably highlights the real quandary in which the citizens of this country find themselves, and why the debate about expanding health insurance under the Obama administration’s Affordable Care Act is so heated. While the increased costs associated with health insurance expansion are undeniable and undisputed, the benefits are less clear, especially in the short-term.
I hope that my upcoming series of columns on health insurance in ENews may help bring some additional light to this complicated issue. The articles should start appearing in September, once the new semester is in full swing.
Joshua Wynne, MD, MBA, MPH
UND Vice President for Health Affairs
Dean, UND School of Medicine and Health Sciences