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Take Two Doses of Caution and Call Me in 2014

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Posted on Mar 24, 2010

By Ruth Marcus

The conventions of political pontification do not allow for admissions of uncertainty or ambivalence. Thus, Sunday night’s House debate on health care featured bombastic declarations from both sides about the impending disaster (Republicans) or nirvana (Democrats) being ushered in.

In fact, the occasion called for more humility than hyperbole, however unlikely that may have been given the setting. If I were a member of Congress, my floor speech before casting a yes vote would have boiled down to:

Gee, I hope this works.

One of the astonishing aspects of the health care debate is how little is actually known about the implications of a change this sweeping. Everyone has a theory, and a model to match, but even some of the most fundamental questions remain the subject of debate. On the most basic of all—does having health insurance lead to better health?—the evidence is solid but not unanimous. The Institute of Medicine, reviewing the literature in 2009, found that “the body of evidence on the health consequences of health insurance is stronger than ever before…. Simply stated: Health insurance coverage matters.”

But a study that same year by Richard Kronick, a former health care adviser to President Clinton, found “little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.” Kronick’s study has been criticized because it did not adjust for the fact that those in poor health are more likely to seek insurance. But the disagreement underscores the difficulty of knowing precisely what changes are in store.


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To take another example, one common assertion has been that the uninsured end up getting health care—just more expensive health care, in emergency rooms and when conditions have worsened, with the costs passed on to the rest of the population. The notion that the tab is being picked up one way or another makes intuitive sense.

A new National Bureau of Economic Research paper by Michael Anderson, Carlos Dobkin and Tal Gross questions this assumption. The researchers examined health care consumption by 19-year-olds who had just been dropped from their parents’ coverage. They found that not having insurance resulted in a 40 percent reduction in emergency room visits—“contradicting the conventional wisdom that the uninsured are more likely to visit” the emergency room—and a 61 percent drop in hospital admissions.

“Overall, these results suggest that an expansion in health insurance coverage would substantially increase the amount of care that currently uninsured individuals receive and require an increase in net expenditures,” the authors write. Emergency room visits could increase by 13 million annually, and hospital admissions by 3.8 million, they project.

So prudence is in order when tinkering with such an interconnected system and when making confident predictions about the effects of reform, for good or ill. Will younger adults, who account for about half the population of the non-elderly adult uninsured, sign up for coverage—or will they pay the fine instead? How will that decision affect premium levels and the adequacy of federal subsidies?

Will the expansion of coverage create a shortage of health care providers and result in higher prices, or will, for example, higher Medicaid payments for primary care doctors stem an exodus of doctors from the program? Will employers add coverage because workers facing the mandate to obtain insurance will press for it, or will they drop it because it will be cheaper to pay the penalty and let employees fend for themselves?

Will increased coverage of preventive care save money because diseases will be caught earlier—or will the added cost of widespread screening exceed the economic benefits? The Congressional Budget Office has concluded that, “for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.”

The legislation is a risk worth taking. Millions of Americans are without insurance, a national scandal that should have been addressed long ago. Rising health care costs threaten the nation’s fiscal security, and the new law holds the promise of beginning to stem the increases.

The status quo is unsustainable. A new study by the Urban Institute shows how, without reform, the numbers of uninsured will rise, employers will continue to drop coverage and premiums will climb.

Still, for those who express cocky certitude about how this is going to turn out, the best prescription is a generous dose of caution.

Ruth Marcus’ e-mail address is marcusr(at symbol)

© 2010, Washington Post Writers Group

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rico, suave's avatar

By rico, suave, March 24, 2010 at 2:44 pm Link to this comment

Point taken. But may I quibble that the amount spent was far from the current level of spending, and the “Star Wars” initiative arguably was successful in helping to end the cold war.

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By Carolina Liberal, March 24, 2010 at 10:39 am Link to this comment
(Unregistered commenter)


Isn’t that exactly what Reagan (and many of the following Presidents) did when they authorized spending billions on “Star Wars?”

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rico, suave's avatar

By rico, suave, March 24, 2010 at 9:02 am Link to this comment

“Gee, I hope this works.”

What if a Republican president had just pushed through a $940 billion dollar weapons system, and said after the fact, “Gee, I hope this works.”

Despite the bad name the extreme wacko elements of the Tea Party Movement give it, their basic complaint is just that. We have just committed nearly a trillion dollars which the govt doesn’t have to a program they aren’t sure is going to work.

What is so nefarious about that?

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johnnyfarout's avatar

By johnnyfarout, March 24, 2010 at 8:36 am Link to this comment

This article is more of the same stupidness about medical care in the USA that’s getting passed around as “thoughts on the conundrum”. Of course you don’t go to the ER if you don’t have insurance, unless you are shooting blood, or half dead, or on your way to the great reward in heaven, which we are sure is wall to wall with Republicans. Insurance reform thinking is the problem. We almost got medical reform, which we need, but got instead an enforced enhancement of the failed model of insurance applied to medical care. Every effort should be put into creating models of total care without impoverishing the people getting it and giving it, which is the scheme perpetrated on Americans now… All around the world are examples to see working completely differently. We are a joke, but sadly this joke is on us and killing us. America is the example of how not to be on planet earth. We are the example of all wrong way thinking and feeling. What is wrong with us? Even giving every kid in school a little laptop, which the phone companies give away for signing up, is objected to as ‘something for nothing”…how stupid. I think rational thought in the social milieu is retarded by market place thinking. We are on the verge of catastrophic doom and all we think about is how to pay our bills in Federal Reserve notes. What are we going to do when they are floating down the streets like so many autumn leaves and our survivors are burning them into carbon foot prints. Think about Jesus I guess and what he would have done. Ahh, there it goes, my free samples of prozac just kicked in, everything will be okay now.

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