8 ms·

Robin Hanson Discusses the Karnataka Health Insurance Experiment

67 points by qualudeheart 5y ago

EdwardDiego 5y ago
So... US being 46th in the world for life expectancy (behind Cuba, ffs...) isn't relevant because? Just saying, there's a lot of first world countries with far higher life expectancy than the US. Access to healthcare might be an answer. (Probably not the only answer though, but likely other answers will be aligned similarly)
- sweezyjeezy 5y ago
  Here's something with some evidence: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222401/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222401/ > Conclusions. The high prevalence of obesity in the United States contributes substantially to its poor international ranking in longevity.
- dunkelheit 5y ago
  > Access to healthcare might be an answer. (Probably not the only answer though, but likely other answers will be aligned similarly) I wonder how much of this is explained by the obesity epidemic. And this isn't something that is solved by better access to healthcare - the best treatment that modern medicine has to offer (diet and exercise) is kind of obvious and accessible to everyone. One can argue that access to healthy and cheap nutrition options matters, but again, this is not something that one would classify as "healthcare".
  - ako 5y ago
    Not sure if healthy food is accessible to everyone: if you're juggling 2 or 3 low-paying jobs you neither have the money nor time to buy and prepare healthy food. In the US fastfood is often cheaper than healthy food.
    - supportlocal4h 5y ago
      You're first sentence points out there are multiple budgets at play (time, money) so it's hard to dispute the ambiguous conclusion. I would guess that your conclusion is true by definition everywhere including the US in terms of time budget. I'm skeptical of its truth for any other budget.
    - rayiner 5y ago
      This is a feel-good trope that doesn’t remotely reflect the typical situation facing lower income people. Fast food is cultural, not economic. If you go to poor Asian and Latino neighborhoods in urban areas, you’ll see ethnic grocery stores underpinning a food culture that is independent of fast food. My poor Bangladeshi immigrant relatives don’t eat fast food; they buy food from the halal grocer and cook. What’s been destroyed among native born American poor people is that food culture.
      - yardie 5y ago
        Fast food is both cultural and economic. Many immigrant households are very traditional and the woman take on the duty of buying and preparing foods. If you are single American, or single parent, working multiple jobs economically it's more convenient to eat fast food. I have rarely seen immigrant men from non-western countries in any type of grocery store shopping for fresh produce.
        rayiner 5y ago
        Being single for an extended time in adulthood, or being a single parent, are cultural as well. And I think the jury is out on “fresh produce” being the key differentiator. It’s hard to find real science that backs that theory up.
        pvg 5y ago
        I have rarely seen immigrant men from non-western countries in any type of grocery store shopping for fresh produce. https://i.redd.it/h4plv5xwq4861.jpg https://i.redd.it/h4plv5xwq4861.jpg
      - 5y ago
- thaumasiotes 5y ago
  > So... US being 46th in the world for life expectancy (behind Cuba, ffs...) isn't relevant because? > Access to healthcare might be an answer. (Probably not the only answer though, but likely other answers will be aligned similarly) I look forward to hearing how Mexican Americans enjoy better access to healthcare than non-Hispanic white Americans.
  - throw55 5y ago
- rayiner 5y ago
  It’s not relevant because the life expectancy numbers don’t correlate well with health insurance access. Asian Americans have slightly lower health insurance access than whites, but live longer than Asians in rich Asian countries with universal healthcare. Hispanic Americans have much lower rates of insurance access, but live as long as people in Denmark. Low American life expectancy seems to result from other factors (obesity, high homicide rates, etc).
  - random314 5y ago
    That's not how you build correlational models. You have to build a survival model and estimate a hazard ratio by access to health insurance, along with other features such as race etc. Otherwise wevcan cherry pick pairs of data points to match up with whatever belief one likes to hold. https://en.wikipedia.org/wiki/Survival_analysis https://en.wikipedia.org/wiki/Survival_analysis Even survival analysis is far from perfect because its correlational, not causal. There are other techniques such as front door criteria etc. to figure these out. https://en.wikipedia.org/wiki/The_Book_of_Why https://en.wikipedia.org/wiki/The_Book_of_Why
  - shard 5y ago
    > Asian Americans have slightly lower health insurance access than whites, but live longer than Asians in rich Asian countries with universal healthcare This is contrary to what I recall reading previously, so I looked up some sources. One study says: “When people come to the United States, they are positively selected, so people coming here are usually younger and healthier,” Baluran said. “What researchers found is that the longer people [immigrants] stay in the U.S., their health begins to deteriorate; by the time [they] reach the second and third generation, the health advantage that immigrants have almost disappeared.” https://asamnews.com/2021/12/23/immigrants-asians-live-healthier-lives-than-those-asians-in-the-country-longer/ https://asamnews.com/2021/12/23/immigrants-asians-live-healt...
    - random314 5y ago
      Fundamentally, the original post is simply cherry picking data. Once you cherry pick, you can arrive at whatever conclusion you like. For example, the data distortion caused by having younger asians in the United states is an example of Simpson's paradox. These can be eliminated using survival analysis https://en.wikipedia.org/wiki/Survival_analysis https://en.wikipedia.org/wiki/Survival_analysis
- inglor_cz 5y ago
  Lifestyle could explain a lot. Standard American diet is horrible and the fact that majority of Americans survive on it until their 70s is a medical miracle. But there are interesting subpopulations. Amish people tend to be healthier in their old age than an average American [0], ethough their total life expectancy is lower (but there is a subset that lives much longer - on average to 85 - and they are subject to genetic studies [1]). Of course, only 4 per cent of Amish are obese, even though their typical diet is not exactly vegetarian (meat, dairy products etc.) [0] https://time.com/5159857/amish-people-stay-healthy-in-old-age-heres-their-secret/ https://time.com/5159857/amish-people-stay-healthy-in-old-ag... [1] https://news.feinberg.northwestern.edu/2017/11/amish-longevity-may-be-due-to-genetic-fountain-of-youth/ https://news.feinberg.northwestern.edu/2017/11/amish-longevi... Mormons also seem to be healthier than average Americans [2]. Of course, the religious ban on tobacco and alcohol might help with that. [2] https://www.latimes.com/archives/la-xpm-1997-04-26-me-52680-story.html https://www.latimes.com/archives/la-xpm-1997-04-26-me-52680-...
  - someguydave 5y ago
    Do you think the carb rich Japanese diet is also horrible?
    - stocknoob 5y ago
      I don’t know, are they averaging 3700 kcal of carbs a day?
- refurb 5y ago
  Life expectancy is a terrible measure for quality of healthcare. First off, it’s not necessarily calculated the same when it comes to stillbirths versus infant deaths, which drastically skew numbers. Second, other factors unrelated or weakly correlated to healthcare systems can impact life expectancy (alcohol use, diet, traffic accidents, suicide). Third, racial differences in longevity.
  - DanBC 5y ago
    How is treatment for substance misuse or suicide not healthcare? > Third, racial differences in longevity. You may want to investigate the healthcare reasons for these.
kchoudhu 5y ago
Is the point of health insurance to increase health, or to insure against catastrophic health failure?
- nix23 5y ago
  Yes exactly, it's written like "when you have insurance you take more medicine which is not healthier" Insurance is normally not for small stuff but big failures...that's why you need insurance (and only for that)..because it's ~impossible to pay for it.
  - mohanmcgeek 5y ago
    Yes. Insurance should be for uncontrollable things like treating things like road accidents, super rare medical conditions etc. But in many countries insurance seems to work like a subscription service that covers everything including things that have a 100% probability of happening (like common cold). Quite naturally, the people who are already paying for it would want to go to the doctor's office and the people who would have to pay for it out of pocket, would not.
- dunkelheit 5y ago
  This is kind of what Hanson is angling at. As I understand it, his thesis is that outside of obvious emergency stuff like infections, tumors, broken bones and such most health impact comes from lifestyle variables such as diet, physical activity, level of stress and quality of sleep. This is not traditionally understood as "medicine" (i.e. something doctors prescribe). But when people have easy access to medicine, they will be compelled to go to doctors more and doctors have an incentive to prescribe more treatments than necessary to maintain the prestige of their profession. So in the end many of these treatments will have either negligible effect on health or even be actively harmful.
  - akdor1154 5y ago
    Yeah that seems TFA's take - i think OP's is (and mine is) that the effect of insurance is that if you're really unlucky and have a catastrophic illness/accident/etc, at least you won't be forced into poverty. This should not then be measured by health outcomes, but economic! It's quite plausible that health outcomes would be similar in aggregate. If you need urgent expensive surgery that takes your home deposit, you'll still pay it and live if you have no other option.
actually_a_dog 5y ago
That 30% reduction in depression sounds pretty good, though. Depression kills.
- erehweb 5y ago
  Mental health is health.
midjji 5y ago
I am a bit dubious about the way this is measured, with rare exceptions the kind of medicine considered healthcare isn't good enough to actually improve these metrics but rater mostly improve quality of life in subtle ways, and the analysis does mention stress reduction/depression reduction. I totally get it reduces stress to have access. But how many things happen to people in a few years that healthcare can actually treat? or at least treat in a way that shows up. I've been to the doctor once or twice a year, but its been twenty plus years since appendicitis which is the one thing in my entire life they could fix which concretely improved health. Vaccines are great, but we generally dont count them into things like this. Painkillers are great for pain, but generally not required. As are splints, physical rehab, stitches and plastic surgery to reduce scarring, but none of which actually improve health in a way measured by studies like this. Dentalcare is great, and the most common form of surgery people truly need, but again, not in studies like this because they are still a part of the blacksmithsguild instead of healthcare for obvious reasons. Antibiotics are great, but its damned rare you actually need them, and a lost week of work doesn't show up in studies like this, and contrary to common opinion, almost all infections go away with soap, rest, and careful cleaning. Breaking a bone and not getting it professionally set is risky, but is more likely to result in permanent pain and minor damage, but it wont kill you, or force you out of work long time. Antihistamines are great, but are available without prescription in most places, With rare exceptions medicine just isn't good enough to actually help, not in a way that measurably improves lifespan. But what it does do is give you something to do about your suffering, and trusting this help exists helps, as does having some rituals to follow when temporarily suffering, massively reduces stress in a way that is worth it for society.
- pas 5y ago
  > Antibiotics are great, but its damned rare you actually need them, and a lost week of work doesn't show up in studies like this, and contrary to common opinion, almost all infections go away with soap, rest, and careful cleaning. I'm glad that even in our shitty underfunded universal healthcare when I had a respiratory infection which did not go away after 1 week of nothing + 1-2 weeks of the typical broad spectrum antibiotics my primary care doctor made an appointment for me for basically immediately at the nearby respiratory care department, and there they made an Xray then prescribed an antibiotic that worked. Sure maybe it would have gone away by then without all this intervention :) > With rare exceptions medicine just isn't good enough to actually help, not in a way that measurably improves lifespan. Yep. Unfortunately we are not there yet. Except the usual success stories of insulin, psychiatric meds, etc.
intended 5y ago
https://tcd.uchicago.edu/projects/value-of-health-insurance-field-experiment-in-india/ https://tcd.uchicago.edu/projects/value-of-health-insurance-...
oli5679 5y ago
If anyone wants some interesting correlational data on life expectancy vs. wealth and health expenditure per capita ourworldindata is a good source. At a country-level the correlational relationships are weaker than many people think. - Costa Rica $14k GDP per capita (2018) $1.1k health expenditure (PPP 2011) has a higher life-expectancy and healthy life-expectancy than - Saudi Arabia $50k GDP per capita (2018) $2.5k health expenditure (PPP 2011) Overall, there is a weak relationship between wealth and health expenditure vs. outcomes beyond $30k GDP/capita and $1.5k expenditure. Many Europeans and North-Americans would expect significantly worse health outcomes using the system of Costa-Rica, Barbados, Uruguay or Turkey, but the data shows similar aggregate outcomes. Of course there are more complexities in understanding the individual data-points. https://ourworldindata.org/grapher/life-expectancy-vs-gdp-per-capita?xScale=linear https://ourworldindata.org/grapher/life-expectancy-vs-gdp-pe... https://ourworldindata.org/grapher/healthy-life-expectancy-vs-health-expenditure-per-capita?xScale=linear https://ourworldindata.org/grapher/healthy-life-expectancy-v...
- dunkelheit 5y ago
  Are those directly comparable though? From what horrors I have heard of the US healthcare system, one can easily pay $5000 for a procedure that someone in my country can easily get just by walking into a private clinic and paying $50 out of pocket. So outstanding health expenditure per capita in the US can just be the symptom of how uniquely bloated their healthcare system is, and not the sign that US citizens use health services so much more.
  - oli5679 5y ago
    Yes, there are lots of factors like this when comparing any two countries. USA does have uniquely high expenditure supporting your bloat claim. The point is other countries e.g. France, Switzerland, Canada, UK, there are also not significant differences vs. countries with lower GDP per capita. I'm not saying this proves a relationship but it's a useful indicative signal, and the randomised studies cited by Hanson, combined with the health outcomes of American Amish all together make more more sceptical of the benefits of health expenditure. I'm not certain though and would love more info. If anyone has any evidence pointing in the opposite direction then would be really interested to see it.
dragonwriter 5y ago
The study at issue is much more limited than the article suggests, and explicitly disclaims applicability for the kind of conclusion it is being used to argue for. From p. 14 of the cited study (interword spacing is somewhat inconsistent because that's how it pastes out of the study PDF): This study is, to our knowledge, the largest experimental evaluation of health insurance in an emerging economy and the first to examine spillover effects. Nevertheless, it has limitations. First, the study was designed to be powered to detect a change in the hospitalization rate, not necessarily changes in health outcomes. Recent research has shown that samples sized in the millions may be required to find effects on rare outcomes, even with insurance that covers not just hospital care, as in this study, but also outpatient care and drugs (Goldin, Lurie et al. 2019). Second, the study examines a plan without coverage for non-surgical outpatient care and prescription drugs. This limits applicability to more comprehensive insurance schemes. Third, while the study helps predict the effect of expanding eligibility under India’s new PMJAY insurance, it does not inform the effects of that plan’s expansion of coverage to non-acute hospital treatments.
- sanxiyn 5y ago
  Eh, the article does mention that point: "It only looked at the effects of hospital treatment, but to many that is the crown jewel of medicine." So health insurance may be useful, but health insurance for hospital treatment isn't. I don't think that conclusion is much weaker.
  - gumby 5y ago
    > Eh, the article does mention that point: "It only looked at the effects of hospital treatment, but to many that is the crown jewel of medicine." What you quote is a mischaracterization by Hanson. From the study (from the GP comment): > the study was designed to be powered to detect a change in the hospitalization rate, not necessarily changes in health outcomes. The interesting questions are: which causes a better gross outcome (what Hanson discusses) and, if outcomes are the same which costs less. If insurance means there is more primary care and that causes less hospitalization then you clearly save money and have a better QoL. Insurance also handles a different class of cases, e.g. you are hit by a car. These are outlier cases (for which insurance makes the most sense and implies no moral hazard). This is ignored by Hanson who considers only baseline chronic conditions like cholesterol levels. The study could imply that insurance coverage could be modified (covering less routine care), though more work would be needed. I’m dubious, but that could be the right thing.
nabla9 5y ago
I suspect every one of these cases the patients were customers of private health care clinics. The motive of the health care could completely change the outcome. In Nordic countries you get the same or better healthcare with less exams and medicines than you get in the US because doctors prescribe treatments and medicine only when necessary.
kgin 5y ago
I take it the RAND Corporation cancelled their employees’ health plans when their study was published.
rayiner 5y ago
Fun fact: Hispanic Americans, who have by far the lowest health insurance access of any group in America, have the second highest life expectancy, after Asian Americans, and we’ll ahead of non-Hispanic whites.
- anovikov 5y ago
  Many cohorts of Hispanic Americans are effectively "immortal", because they go back to their origin countries by the end of their lives to retire on money made in the USA... So it's hard to make conclusions based on them.
  - refurb 5y ago
    I’m sorry what? You think the US tracks people through out their life and assumes they are alive unless otherwise proven? No, they just look at deaths. If someone leaves the US, their life expectancy isn’t counted.
- pessimizer 5y ago
  All other things being equal, shorter people live longer. Less volume to get cancer in, among other things. Hispanic-Americans will on average live longer, Asian-Americans will on average live longer, women will on average live longer. Random citation: https://pubmed.ncbi.nlm.nih.gov/12586217/ https://pubmed.ncbi.nlm.nih.gov/12586217/ Do you have any study about what you're saying that controls for height? ----- edit: for example... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071721/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071721/ Table 1 Age-standardized death rates from all causes, coronary heart disease(CHD), and stroke per 100,000 population (males) for 6 ethnic groups in California Ethnic groups* Height, cm (in) Age-standardized death rates/100,000 All cause CHD Stroke African American 178 (70) 1,800 316 102 White 178 (70) 1,243 302 60 Hispanic 172 (68) 856 175 49 Asian Indian† 170 (67) 668 258 33 Chinese 169 (66) 773 155 62 Japanese 169 (66) 693 146 52 *In order of decreasing height. †Based on height data for upper socioeconomic status in India.

67 points by qualudeheart 5y ago

So... US being 46th in the world for life expectancy (behind Cuba, ffs...) isn't relevant because? Just saying, there's a lot of first world countries with far higher life expectancy than the US. Access to healthcare might be an answer. (Probably not the only answer though, but likely other answers will be aligned similarly)

sweezyjeezy 5y ago
Here's something with some evidence: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222401/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222401/ > Conclusions. The high prevalence of obesity in the United States contributes substantially to its poor international ranking in longevity.
dunkelheit 5y ago
> Access to healthcare might be an answer. (Probably not the only answer though, but likely other answers will be aligned similarly) I wonder how much of this is explained by the obesity epidemic. And this isn't something that is solved by better access to healthcare - the best treatment that modern medicine has to offer (diet and exercise) is kind of obvious and accessible to everyone. One can argue that access to healthy and cheap nutrition options matters, but again, this is not something that one would classify as "healthcare".
- ako 5y ago
  Not sure if healthy food is accessible to everyone: if you're juggling 2 or 3 low-paying jobs you neither have the money nor time to buy and prepare healthy food. In the US fastfood is often cheaper than healthy food.
  - supportlocal4h 5y ago
    You're first sentence points out there are multiple budgets at play (time, money) so it's hard to dispute the ambiguous conclusion. I would guess that your conclusion is true by definition everywhere including the US in terms of time budget. I'm skeptical of its truth for any other budget.
  - rayiner 5y ago
    This is a feel-good trope that doesn’t remotely reflect the typical situation facing lower income people. Fast food is cultural, not economic. If you go to poor Asian and Latino neighborhoods in urban areas, you’ll see ethnic grocery stores underpinning a food culture that is independent of fast food. My poor Bangladeshi immigrant relatives don’t eat fast food; they buy food from the halal grocer and cook. What’s been destroyed among native born American poor people is that food culture.
    - yardie 5y ago
      Fast food is both cultural and economic. Many immigrant households are very traditional and the woman take on the duty of buying and preparing foods. If you are single American, or single parent, working multiple jobs economically it's more convenient to eat fast food. I have rarely seen immigrant men from non-western countries in any type of grocery store shopping for fresh produce.
      - rayiner 5y ago
        Being single for an extended time in adulthood, or being a single parent, are cultural as well. And I think the jury is out on “fresh produce” being the key differentiator. It’s hard to find real science that backs that theory up.
      - pvg 5y ago
        I have rarely seen immigrant men from non-western countries in any type of grocery store shopping for fresh produce. https://i.redd.it/h4plv5xwq4861.jpg https://i.redd.it/h4plv5xwq4861.jpg
    - 5y ago
thaumasiotes 5y ago
> So... US being 46th in the world for life expectancy (behind Cuba, ffs...) isn't relevant because? > Access to healthcare might be an answer. (Probably not the only answer though, but likely other answers will be aligned similarly) I look forward to hearing how Mexican Americans enjoy better access to healthcare than non-Hispanic white Americans.
- throw55 5y ago
rayiner 5y ago
It’s not relevant because the life expectancy numbers don’t correlate well with health insurance access. Asian Americans have slightly lower health insurance access than whites, but live longer than Asians in rich Asian countries with universal healthcare. Hispanic Americans have much lower rates of insurance access, but live as long as people in Denmark. Low American life expectancy seems to result from other factors (obesity, high homicide rates, etc).
- random314 5y ago
  That's not how you build correlational models. You have to build a survival model and estimate a hazard ratio by access to health insurance, along with other features such as race etc. Otherwise wevcan cherry pick pairs of data points to match up with whatever belief one likes to hold. https://en.wikipedia.org/wiki/Survival_analysis https://en.wikipedia.org/wiki/Survival_analysis Even survival analysis is far from perfect because its correlational, not causal. There are other techniques such as front door criteria etc. to figure these out. https://en.wikipedia.org/wiki/The_Book_of_Why https://en.wikipedia.org/wiki/The_Book_of_Why
- shard 5y ago
  > Asian Americans have slightly lower health insurance access than whites, but live longer than Asians in rich Asian countries with universal healthcare This is contrary to what I recall reading previously, so I looked up some sources. One study says: “When people come to the United States, they are positively selected, so people coming here are usually younger and healthier,” Baluran said. “What researchers found is that the longer people [immigrants] stay in the U.S., their health begins to deteriorate; by the time [they] reach the second and third generation, the health advantage that immigrants have almost disappeared.” https://asamnews.com/2021/12/23/immigrants-asians-live-healthier-lives-than-those-asians-in-the-country-longer/ https://asamnews.com/2021/12/23/immigrants-asians-live-healt...
  - random314 5y ago
    Fundamentally, the original post is simply cherry picking data. Once you cherry pick, you can arrive at whatever conclusion you like. For example, the data distortion caused by having younger asians in the United states is an example of Simpson's paradox. These can be eliminated using survival analysis https://en.wikipedia.org/wiki/Survival_analysis https://en.wikipedia.org/wiki/Survival_analysis
inglor_cz 5y ago
Lifestyle could explain a lot. Standard American diet is horrible and the fact that majority of Americans survive on it until their 70s is a medical miracle. But there are interesting subpopulations. Amish people tend to be healthier in their old age than an average American [0], ethough their total life expectancy is lower (but there is a subset that lives much longer - on average to 85 - and they are subject to genetic studies [1]). Of course, only 4 per cent of Amish are obese, even though their typical diet is not exactly vegetarian (meat, dairy products etc.) [0] https://time.com/5159857/amish-people-stay-healthy-in-old-age-heres-their-secret/ https://time.com/5159857/amish-people-stay-healthy-in-old-ag... [1] https://news.feinberg.northwestern.edu/2017/11/amish-longevity-may-be-due-to-genetic-fountain-of-youth/ https://news.feinberg.northwestern.edu/2017/11/amish-longevi... Mormons also seem to be healthier than average Americans [2]. Of course, the religious ban on tobacco and alcohol might help with that. [2] https://www.latimes.com/archives/la-xpm-1997-04-26-me-52680-story.html https://www.latimes.com/archives/la-xpm-1997-04-26-me-52680-...
- someguydave 5y ago
  Do you think the carb rich Japanese diet is also horrible?
  - stocknoob 5y ago
    I don’t know, are they averaging 3700 kcal of carbs a day?
refurb 5y ago
Life expectancy is a terrible measure for quality of healthcare. First off, it’s not necessarily calculated the same when it comes to stillbirths versus infant deaths, which drastically skew numbers. Second, other factors unrelated or weakly correlated to healthcare systems can impact life expectancy (alcohol use, diet, traffic accidents, suicide). Third, racial differences in longevity.
- DanBC 5y ago
  How is treatment for substance misuse or suicide not healthcare? > Third, racial differences in longevity. You may want to investigate the healthcare reasons for these.

kchoudhu 5y ago

Is the point of health insurance to increase health, or to insure against catastrophic health failure?

nix23 5y ago
Yes exactly, it's written like "when you have insurance you take more medicine which is not healthier" Insurance is normally not for small stuff but big failures...that's why you need insurance (and only for that)..because it's ~impossible to pay for it.
- mohanmcgeek 5y ago
  Yes. Insurance should be for uncontrollable things like treating things like road accidents, super rare medical conditions etc. But in many countries insurance seems to work like a subscription service that covers everything including things that have a 100% probability of happening (like common cold). Quite naturally, the people who are already paying for it would want to go to the doctor's office and the people who would have to pay for it out of pocket, would not.
dunkelheit 5y ago
This is kind of what Hanson is angling at. As I understand it, his thesis is that outside of obvious emergency stuff like infections, tumors, broken bones and such most health impact comes from lifestyle variables such as diet, physical activity, level of stress and quality of sleep. This is not traditionally understood as "medicine" (i.e. something doctors prescribe). But when people have easy access to medicine, they will be compelled to go to doctors more and doctors have an incentive to prescribe more treatments than necessary to maintain the prestige of their profession. So in the end many of these treatments will have either negligible effect on health or even be actively harmful.
- akdor1154 5y ago
  Yeah that seems TFA's take - i think OP's is (and mine is) that the effect of insurance is that if you're really unlucky and have a catastrophic illness/accident/etc, at least you won't be forced into poverty. This should not then be measured by health outcomes, but economic! It's quite plausible that health outcomes would be similar in aggregate. If you need urgent expensive surgery that takes your home deposit, you'll still pay it and live if you have no other option.

actually_a_dog 5y ago

That 30% reduction in depression sounds pretty good, though. Depression kills.

erehweb 5y ago
Mental health is health.

midjji 5y ago

I am a bit dubious about the way this is measured, with rare exceptions the kind of medicine considered healthcare isn't good enough to actually improve these metrics but rater mostly improve quality of life in subtle ways, and the analysis does mention stress reduction/depression reduction. I totally get it reduces stress to have access. But how many things happen to people in a few years that healthcare can actually treat? or at least treat in a way that shows up. I've been to the doctor once or twice a year, but its been twenty plus years since appendicitis which is the one thing in my entire life they could fix which concretely improved health. Vaccines are great, but we generally dont count them into things like this. Painkillers are great for pain, but generally not required. As are splints, physical rehab, stitches and plastic surgery to reduce scarring, but none of which actually improve health in a way measured by studies like this. Dentalcare is great, and the most common form of surgery people truly need, but again, not in studies like this because they are still a part of the blacksmithsguild instead of healthcare for obvious reasons. Antibiotics are great, but its damned rare you actually need them, and a lost week of work doesn't show up in studies like this, and contrary to common opinion, almost all infections go away with soap, rest, and careful cleaning. Breaking a bone and not getting it professionally set is risky, but is more likely to result in permanent pain and minor damage, but it wont kill you, or force you out of work long time. Antihistamines are great, but are available without prescription in most places, With rare exceptions medicine just isn't good enough to actually help, not in a way that measurably improves lifespan. But what it does do is give you something to do about your suffering, and trusting this help exists helps, as does having some rituals to follow when temporarily suffering, massively reduces stress in a way that is worth it for society.

pas 5y ago
> Antibiotics are great, but its damned rare you actually need them, and a lost week of work doesn't show up in studies like this, and contrary to common opinion, almost all infections go away with soap, rest, and careful cleaning. I'm glad that even in our shitty underfunded universal healthcare when I had a respiratory infection which did not go away after 1 week of nothing + 1-2 weeks of the typical broad spectrum antibiotics my primary care doctor made an appointment for me for basically immediately at the nearby respiratory care department, and there they made an Xray then prescribed an antibiotic that worked. Sure maybe it would have gone away by then without all this intervention :) > With rare exceptions medicine just isn't good enough to actually help, not in a way that measurably improves lifespan. Yep. Unfortunately we are not there yet. Except the usual success stories of insulin, psychiatric meds, etc.

intended 5y ago

https://tcd.uchicago.edu/projects/value-of-health-insurance-field-experiment-in-india/ https://tcd.uchicago.edu/projects/value-of-health-insurance-...

oli5679 5y ago

If anyone wants some interesting correlational data on life expectancy vs. wealth and health expenditure per capita ourworldindata is a good source. At a country-level the correlational relationships are weaker than many people think. - Costa Rica $14k GDP per capita (2018) $1.1k health expenditure (PPP 2011) has a higher life-expectancy and healthy life-expectancy than - Saudi Arabia $50k GDP per capita (2018) $2.5k health expenditure (PPP 2011) Overall, there is a weak relationship between wealth and health expenditure vs. outcomes beyond $30k GDP/capita and $1.5k expenditure. Many Europeans and North-Americans would expect significantly worse health outcomes using the system of Costa-Rica, Barbados, Uruguay or Turkey, but the data shows similar aggregate outcomes. Of course there are more complexities in understanding the individual data-points. https://ourworldindata.org/grapher/life-expectancy-vs-gdp-per-capita?xScale=linear https://ourworldindata.org/grapher/life-expectancy-vs-gdp-pe... https://ourworldindata.org/grapher/healthy-life-expectancy-vs-health-expenditure-per-capita?xScale=linear https://ourworldindata.org/grapher/healthy-life-expectancy-v...

dunkelheit 5y ago
Are those directly comparable though? From what horrors I have heard of the US healthcare system, one can easily pay $5000 for a procedure that someone in my country can easily get just by walking into a private clinic and paying $50 out of pocket. So outstanding health expenditure per capita in the US can just be the symptom of how uniquely bloated their healthcare system is, and not the sign that US citizens use health services so much more.
- oli5679 5y ago
  Yes, there are lots of factors like this when comparing any two countries. USA does have uniquely high expenditure supporting your bloat claim. The point is other countries e.g. France, Switzerland, Canada, UK, there are also not significant differences vs. countries with lower GDP per capita. I'm not saying this proves a relationship but it's a useful indicative signal, and the randomised studies cited by Hanson, combined with the health outcomes of American Amish all together make more more sceptical of the benefits of health expenditure. I'm not certain though and would love more info. If anyone has any evidence pointing in the opposite direction then would be really interested to see it.

dragonwriter 5y ago

The study at issue is much more limited than the article suggests, and explicitly disclaims applicability for the kind of conclusion it is being used to argue for. From p. 14 of the cited study (interword spacing is somewhat inconsistent because that's how it pastes out of the study PDF): This study is, to our knowledge, the largest experimental evaluation of health insurance in an emerging economy and the first to examine spillover effects. Nevertheless, it has limitations. First, the study was designed to be powered to detect a change in the hospitalization rate, not necessarily changes in health outcomes. Recent research has shown that samples sized in the millions may be required to find effects on rare outcomes, even with insurance that covers not just hospital care, as in this study, but also outpatient care and drugs (Goldin, Lurie et al. 2019). Second, the study examines a plan without coverage for non-surgical outpatient care and prescription drugs. This limits applicability to more comprehensive insurance schemes. Third, while the study helps predict the effect of expanding eligibility under India’s new PMJAY insurance, it does not inform the effects of that plan’s expansion of coverage to non-acute hospital treatments.

sanxiyn 5y ago
Eh, the article does mention that point: "It only looked at the effects of hospital treatment, but to many that is the crown jewel of medicine." So health insurance may be useful, but health insurance for hospital treatment isn't. I don't think that conclusion is much weaker.
- gumby 5y ago
  > Eh, the article does mention that point: "It only looked at the effects of hospital treatment, but to many that is the crown jewel of medicine." What you quote is a mischaracterization by Hanson. From the study (from the GP comment): > the study was designed to be powered to detect a change in the hospitalization rate, not necessarily changes in health outcomes. The interesting questions are: which causes a better gross outcome (what Hanson discusses) and, if outcomes are the same which costs less. If insurance means there is more primary care and that causes less hospitalization then you clearly save money and have a better QoL. Insurance also handles a different class of cases, e.g. you are hit by a car. These are outlier cases (for which insurance makes the most sense and implies no moral hazard). This is ignored by Hanson who considers only baseline chronic conditions like cholesterol levels. The study could imply that insurance coverage could be modified (covering less routine care), though more work would be needed. I’m dubious, but that could be the right thing.

nabla9 5y ago

I suspect every one of these cases the patients were customers of private health care clinics. The motive of the health care could completely change the outcome. In Nordic countries you get the same or better healthcare with less exams and medicines than you get in the US because doctors prescribe treatments and medicine only when necessary.

kgin 5y ago

I take it the RAND Corporation cancelled their employees’ health plans when their study was published.

rayiner 5y ago

Fun fact: Hispanic Americans, who have by far the lowest health insurance access of any group in America, have the second highest life expectancy, after Asian Americans, and we’ll ahead of non-Hispanic whites.

anovikov 5y ago
Many cohorts of Hispanic Americans are effectively "immortal", because they go back to their origin countries by the end of their lives to retire on money made in the USA... So it's hard to make conclusions based on them.
- refurb 5y ago
  I’m sorry what? You think the US tracks people through out their life and assumes they are alive unless otherwise proven? No, they just look at deaths. If someone leaves the US, their life expectancy isn’t counted.
pessimizer 5y ago
All other things being equal, shorter people live longer. Less volume to get cancer in, among other things. Hispanic-Americans will on average live longer, Asian-Americans will on average live longer, women will on average live longer. Random citation: https://pubmed.ncbi.nlm.nih.gov/12586217/ https://pubmed.ncbi.nlm.nih.gov/12586217/ Do you have any study about what you're saying that controls for height? ----- edit: for example... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071721/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071721/ Table 1 Age-standardized death rates from all causes, coronary heart disease(CHD), and stroke per 100,000 population (males) for 6 ethnic groups in California Ethnic groups* Height, cm (in) Age-standardized death rates/100,000 All cause CHD Stroke African American 178 (70) 1,800 316 102 White 178 (70) 1,243 302 60 Hispanic 172 (68) 856 175 49 Asian Indian† 170 (67) 668 258 33 Chinese 169 (66) 773 155 62 Japanese 169 (66) 693 146 52 *In order of decreasing height. †Based on height data for upper socioeconomic status in India.