Does Insurance Matter?

Published November 1, 2006

Skeptics of single-payer health care got a gift from the Rand Corporation and the prestigious New England Journal of Medicine in March 2006, but no one on the left or the right recognized its true meaning at the time.

Survey Says

The authors of the study, titled “Who is at Greatest Risk for Receiving Poor-Quality Health Care?” declared that everyone in the United States receives equally poor care, regardless of age, insurance status, or race.

The study was based on interviews and a medical records review of more than 14,000 people, using a 439 item list presumed to show the quality of health care received.

The analysis showed people received an average of 54.9 percent of the recommended health care.

According to the study, women (56 percent) received more care than men (52 percent); people under age 31 (57 percent) more than those over 64 (52 percent); and blacks and Hispanics (57 percent) more than whites (54 percent). People earning more than $50,000 a year scored their care at 56 percent, while people reporting household incomes of less than $15,000 scored it 53 percent.

The 439 items used in the study are typical of the lists used by health wonks–the length of which helps explain why both the World Health Organization and Rand rate countries with poor medical systems more highly than the United States. Third World physicians score higher because they have to do what public health authorities demand. American physicians work with comparative freedom and are less likely to worry about some of the items on these lists.

Devil in the Details

While the list was probably too detailed for high scores to be possible among U.S. doctors, the closeness of the scores for different populations may be more telling. A few percentage points’ difference in a population study means the results are essentially the same.

The results show (with my analysis in parentheses):

  • Women generally got better care than men (because they insist on it and seek medical assistance more often);
  • Younger people got better care than older people (because older people needed more items checked and younger people fewer); and
  • Blacks, Hispanics, and the poor scored high (because they go to public clinics and institutions more often, and health care checklists are popular with those institutions. Private doctors don’t like lists very much).

No Bias

In the discussion section, the study’s authors congratulate themselves on the report’s comprehensiveness, puzzle over the better scores for “oppressed” groups, and seem clueless on the issue of the day: that insurance didn’t seem to improve quality of care. But they found their voice and hit high C when pointing out their work confirmed the poor quality of American health care for everyone.

In their rush to condemn the overall quality of care, however, the Rand authors accidentally proved race, sex, and income don’t measurably affect it. Why, then, have Americans been barraged with hundreds of research papers in the past 20 years about the cruelty, racism, and sexism of America’s inefficient health care system?

The medical literature since 1985 has shown a dramatic increase in this sort of gratuitous criticism of the American health care system. Some academic medical commentators and public health officials have expressed an uncontrolled and noisy scorn for regular American hospitals and doctors. We now know this animus is not based on any real inequality in health care.

So what drives the campaign against private health care? Could it be the political rewards of placing the biggest sector of the economy under government control?

The Rand study exposes many of these critics of America’s health care system as advocates for social and economic changes intended to bring health care into the government. They claim the system is broken, and that means politicians must step in.

Insurance Doesn’t Matter

In addition, the finding that insurance doesn’t matter–at least, not according to the checklists the Rand experts and others think should be used to replace doctors’ judgment–deserves more attention than it has received from both sides of the debate.

If health insurance doesn’t improve health care, how could a single-payer system be an improvement? A single-payer system “solves” the uninsured problem, but the Rand study now “proves” there is no uninsured problem: The uninsured get the same quality of care as the insured.

Given that universal health insurance cannot improve the quality of care, advocates of single-payer systems now have to persuade us that the benefits of their scheme would stem from Soviet-style central planning and rationing.

That’s a difficult case to make, since it is well known that welfare-state medicine is mediocre when it comes to actually providing care to sick people.

The Rand study provides a great argument for a reanalysis of what makes for high-quality health care, or at least whether long lists are the best measure.

It also raises another question: Is the American health care system better than its enemies in the academy and in think tanks are willing to admit?

John Dale Dunn, M.D., J.D. ([email protected]) is a health care consultant and mediator in Lake Brownwood, Texas.

For more information …

Steven M. Asch et al., “Who Is at Greatest Risk for Receiving Poor-Quality Health Care?” New England Journal of Medicine, Vol. 354, No. 11, March 16, 2006, pp. 1147-1156: