Death and the Uninsured
During the recent Democrat Party Convention in Denver, a local
nonprofit ran an advertisement in USA Today and many of
Colorado's major newspapers urging elected officials to solve the
nation's health care crisis. The ad, purchased by the liberal
Colorado Health Foundation, claimed that "Every year, 18,000
Americans die because they don't have health insurance."
That statistic of deaths due to lack of health insurance has
been frequently cited in health care debates since the Institute of
Medicine (IOM) reported it in 2002. A recent update from the liberal Urban Institute showed that the
number of deaths due to lack of health insurance had subsequently
increased to 22,000.
Yet the statistic has come under increasing fire by critics who
questions its accuracy. Linda Gorman, a senior fellow with the
conservative Independence Institute in Denver, said, "It's not a
robust result. You don't make good public policy on such
results."
Chris Power-Bain, senior communications officer at the Colorado
Health Foundation, defends the statistic. "The Institute of
Medicine is a credible source of information. Further, there is a
growing body of evidence showing a strong relationship between
health outcomes and insurance."
One concern cited by Gorman is the wide degree of uncertainty
surrounding the statistic. "Care Without Coverage," the 2002 IOM
report, based the statistic on an earlier study in the Journal of the American
Medical Association (JAMA). That study found that
lacking health insurance increased the risk of mortality by
25%.
One can follow the IOM's methodology in determining death due to
uninsurance by reading the Urban Institute report. In short, the
IOM used the statistic from the JAMA study to calculate
how many people would have died if everyone in the U.S. was
insured. It then subtracted that number from the number of people
who did die to determine the number of people who died due to lack
of insurance.
The problem lies in the statistic in the original JAMA
study. Specifically, the data in that study could not rule out the
possibility that lacking insurance has no effect on
mortality. Nor could it rule out that the effect might be larger,
up to 55%. Thus, it is possible that the number of deaths annually
due to uninsurance could be as low as zero or as high as
47,000.
Wilhelmine Miller, an associate research professor in the
Department of Health Policy at George Washington University and the
director of IOM report, defends the report. "We made some judgments
about what studies to use," she said. "The ones we used were
methodologically strong."
Helen Levy, research assistant professor at the University of
Michigan's Institute for Social Research, disagrees. "The basis for
the (IOM) number is ridiculous. Lots of other things affect those
deaths."
Health outcomes are affected by many factors, including income,
education level, smoking, and diet. Those factors also affect
insurance status, making it difficult to discern the exact effect
lack of insurance has on mortality.
An additional problem is that some people are uninsured for
brief periods while others are uninsured for longer period of time,
something which studies linking mortality to insurance often don't
account for. Richard Kronick, professor of family and preventive
medicine at the University of California at San Diego, said, "That
likely understates the problem. If you could control for insurance
status over a longer period, the real effect might be bigger."
Jack Hadley, a principal research associate at the Urban
Institute, concurs. Studies he has conducted that follow the
insurance status of the older Americans over time show that
uninsurance "tends to have a somewhat large effect on mortality,"
he said. "More recent studies show that the relation between
insurance and morality is pretty robust." However, those studies do
not form the basis for the 18,000 figure.
There is also considerable debate over whether increasing the
number of people with insurance is the best way to improve health
outcomes. Michael Cannon, director of health policy studies at the
libertarian Cato Institute, said, "There is no evidence that health
insurance will deliver better outcomes than spending money on other
things. Money spent on community health centers, nutrition programs
or improving education may have a stronger impact."
Hadley, however, points to problems with that approach, noting
that some approaches are easier than others. "You can give everyone
insurance tomorrow. You can't give everyone a college education
that quickly."
Of course, giving everyone government-funded insurance would
prove extremely costly. Before we, as a society, decide to pay that
cost, we must know with some certainty the cost of not providing
insurance. And right now, the statistic on deaths from uninsurance
is anything but certain.
Balanced Budget Conservatism
The Congressional Budget Office recently estimated that the
federal budget deficit for fiscal year 2007 will be about $158
billion, $90 billion less than last year. At that rate, we might
well have a budget surplus within two years. Of course, that
depends on many different factors, including the extent to which
Congress and the President control spending and whether the economy
continues to grow. Since a surplus seems likely, conservatives
should be prepared for it. In that spirit, let me propose what I
call "Balanced Budget Conservatism."
Balanced Budget Conservatism starts with the premise that any
surplus should first be used to create personal savings that will
be used to stave off the coming entitlement crisis. When the
surplus returns, many conservatives will have a noble desire to use
the surplus to cut taxes. (And by "tax cuts" I do not mean extend
the Bush tax cuts. Those should be extended regardless. By tax cuts
I mean going beyond the Bush tax cuts.) And, surely, a good
argument can be made for that course of action. But a better case
can be made for using the surplus to create personal savings.
If we use the surplus for tax cuts, those tax cuts could easily
prove ephemeral. We might have to give them back at a future point
in order to pay for the coming shortfalls in Social Security and
Medicare. Thus, to preserve the tax cuts we have now, we should use
any surplus to save for the coming entitlement crisis.
Politicians and pundits should emphasize that the surplus
belongs to the American people, and the best way to ensure that
they have it is by using the surplus to create personal accounts.
The surplus should be used to create two personal accounts for
every working American under age 55, one for Social Security and
one for Medicare. Money would only go into the accounts as long as
the government was running a surplus. Individuals would have the
choice of different index funds in which to invest these
accounts.
If this is sounding a lot like Bush's abortive attempt at Social
Security reform in 2005, you are right. But there are some key
differences this time. First, it will not require any "carve out"
from the current payroll tax to create the accounts. Second, we do
not have to discuss any future benefit adjustments at this point,
such as moving from wage indexing to price indexing for Social
Security benefits. Indeed, conservatives should avoid any
discussion of benefit cuts for the time being. They should only
emphasize that the personal accounts are to empower the American
people, their children, and their grandchildren to create savings
that will protect them against the coming entitlement crisis.
Finally, using a budget surplus avoids deficit funding of the
accounts.
Using the surplus to create accounts will have the added benefit
of putting downward pressure on spending. If spending takes off, it
will eat up the surplus resulting in no money for personal
accounts. It will be easy for conservatives to criticize more
liberal politicians for spending money that should be going into
people's individual accounts. Unless politicians want to face the
wrath of voters who are no longer seeing funds going into their
accounts, they will be far more hesitant to increase spending
beyond reasonable levels.
In order to sell Balance Budget Conservatism to the public,
politicians and pundits on the right must emphasize that the
accounts create ownership, personal property and savings for
individuals. For the time being, they should avoid talking about
benefit cuts. That is a discussion for a future date, one that will
be made much easier when individuals have accumulated savings to
rely on.
If and when surpluses return, conservatives need to be ready
with a game plan. Balanced Budget Conservatism provides us with
one.
*****
Final Note: This is my last column in The
American Spectator for the foreseeable future. I am taking a
job on Capitol Hill, working on many policy issues including health
care. With health care policy likely to be a major issue for the
next two years, a chance to work on the inside of the policy
process is an opportunity I cannot pass up. It's been a great run,
and I am forever appreciative of the editors
