Pertinent unasked question of the day

James Freeman begins with Comrade Sanders’ over-the-top rhetoric:

Vermont Socialist Sen. Bernie Sanders deplored the actions of his former campaign volunteer James T. Hodgkinson, who was killed after opening fire on participants at a congressional baseball practice for Republicans on June 14. More recently, Mr. Sanders has been accusing his Republican colleagues of hatching a plan that will result in thousands of deaths.

The anti-Trump ”resistance,” still smarting from its recent loss in a Georgia House race, has apparently decided that it needs someone more radical than Rep. Nancy Pelosi (D., Calif.) to lead the opposition to GOP health care reforms. So the organization MoveOn.org has been staging a multi-state tour with Mr. Sanders as the headliner.

The basic Sanders argument, which he has been articulating in various fora in recent days, is that fewer people on government insurance plans will mean more people dying. It seems likely that any health reform plan that makes it to the President’s desk will no longer force people to buy ObamaCare plans, and will give states at least some flexibility in choosing not to provide insurance to people who aren’t sick, aren’t poor and don’t have children.

But will fewer people on government-mandated insurance plans automatically make them less healthy? Mr. Sanders appears to be convinced. He tweeted on Friday: “Let us be clear and this is not trying to be overly dramatic: Thousands of people will die if the Republican health care bill becomes law.” Asked to defend such remarks on NBC’s “Meet the Press” on Sunday, Mr. Sanders said:

I wish I didn’t have to say it. This is not me. This is study after study making this point. It is common sense. If you have cancer and your insurance is taken away from you, there is a likelihood you will die and certainly a likelihood that you will become much sicker than you are today. That’s the fact. Unpleasant, but it’s true.

Speaking of studies, all of America has been participating in an experiment since 2010 to see if a federal effort to extend government-mandated insurance coverage to millions more people can improve our lives. Last year the Obama Administration bragged that 20 million adults had gained health insurance as a result of Mr. Obama’s so-called Affordable Care Act.

Given the Sanders logic, one might have expected to see a corresponding improvement in public health. But so far evidence that ObamaCare made us healthier has proven elusive, to say the least. In December the New York Times was among the many news outlets that had to share the embarrassing news:

American life expectancy is in decline for the first time since 1993, when H.I.V.-related deaths were at their peak. But this time, researchers can’t identify a single problem driving the drop, and are instead pointing to a number of factors, from heart disease to suicides, that have caused a greater number of deaths.

A study on mortality rates released on Thursday by the National Center for Health Statistics showed that Americans could expect to live for 78.8 years in 2015, a decrease of 0.1 from the year before. The overall death rate increased 1.2 percent — that’s about 86,212 more deaths than those recorded in 2014.

Dr. Peter Muennig, a professor of health policy and management at Columbia University’s Mailman School of Public Health, said in an interview that the decline was a “uniquely American phenomenon” in comparison with other developed countries, like Japan or Sweden.

“A 0.1 decrease is huge,” Dr. Muennig said. “Life expectancy increases, and that’s very consistent and predictable, so to see it decrease, that’s very alarming.”

It sure is. One thing on which researchers seem to agree is that there has been a deterioration in the health of middle-class whites. Why is this group seeing higher mortality rates? In a recent paper for the Brookings Institution, Nobel Prize-winning economist Angus Deaton and his Princeton colleague Anne Case write:

We propose a preliminary but plausible story in which cumulative disadvantage over life, in the labor market, in marriage and child outcomes, and in health, is triggered by progressively worsening labor market opportunities at the time of entry for whites with low levels of education.

Much of Mr. Deaton’s research over the years has examined the way that people around the world get healthier as they get wealthier. Republicans should note that expanding employment is a great way to improve wellness. This is of course the opposite of the agenda embedded in ObamaCare, which discouraged employment. It’s hard to tell if Mr. Sanders will regret raising the question of whether government insurance programs are the key to health and longevity. But it’s an argument he is not going to win.

Actually, we knew about the non-relationship between health care spending and better health even before ObamaCare. Democrats have been hectoring Gov. Scott Walker to expand Medicaid despite the fact that in a state similar to Wisconsin that did expand Medicaid, Oregon, substantially higher Medicaid spending led to more health care use, but not better results.

Sanders probably won’t mention this inconvenience either, reported by The Federalist:

More people have health insurance, so more people are benefitting from improved health outcomes and access to care.

There is only one simple flaw in this reasoning. It does not appear to be true. …

In December 2009, the American Journal of Public Health published an important study. Dr. Andrew Wilper and five colleagues from the Cambridge Health Alliance updated a 1993 study using data from the Third National Health and Nutrition Examination Survey. It found that private health care insurance was associated in 2005 with a 40 percent mortality risk reduction among the pre-Medicare U.S. adult population (age 18 to 64). This association was robust after controlling for numerous co-variables.

To put numbers on it, reducing the risk of death by 40 percent among the 2005 uninsured population would eliminate up to 45,000 premature deaths of adult Americans. This study had a huge effect on the political debate surrounding Obamacare. A search of “Harvard study 45,000 deaths” reveals more than 500,000 hits. …

Fifteen million newly insured Americans is a big change in the U.S. insured population and, using Wilper’s numbers, population-level mortality statistics should clearly convey a reduction. Specifically, using Wilper’s 40 percent mortality risk reduction with 15 million newly insured people means that approximately 21,000 fewer adult Americans should die in 2015 relative to the pre-Obamacare status quo.

The Centers for Disease Control collects U.S. mortality statistics and publishes them in a database called WONDER. The database is indeed a statistical wonder, allowing researchers to slice and dice U.S. mortality data into segments by age, gender, location, year, cause of morbidity, and many additional criteria.

With WONDER, it is a short exercise to attempt to confirm Wilper’s predictions. Examining U.S. adult mortality in the decade prior to Obamacare’s insurance expansion (2004-2013), the all-cause mean death rate for ages 15 to 64 is 310.4 people per 100,000. The rate is fairly steady over the decade, with a low of 306.8, a high of 313.5, and a standard deviation of 2.2. If extending taxpayer-sponsored insurance to 15 million people since 2013 has resulted in 21,000 fewer annual deaths, then the mean death rate should decrease from 310.4 to approximately 300.

Returning to the WONDER database for 2014-15 numbers, one finds the mean death rate is … 320.4. Well, that is unexpected. Since Obamacare provisions extended insurance coverage, the death rate has substantially increased, by more than 20,000 deaths per year.

A correlation does not prove causation, of course, and since we believe health insurance reduces mortality, there must be a coincident event causing the spike in deaths since 2014. And there is an apparent scapegoat. An opioid crisis has gripped the United States since Obamacare insurance expansion was implemented.

Opioids have caused thousands of early deaths, enough to distort mortality statistics in adult Americans, and the crisis worsened noticeably in 2014-2015. Assuming the opioid crisis is independent of Obamacare insurance expansion (for analysis purposes only, since some work has suggested these two phenomena may be causally linked) may eliminate the excess deaths and show the expected reduced mortality from health care insurance.

Fortunately, WONDER allows researchers to separate causes of morbidity, so it is a simple matter to repeat the analysis, excluding drug-related and other external causes of death, and clear up the confusion about the increased U.S. mortality.

What happens when we calculate the death rate after excluding all external causes of morbidity (ICD-10 codes for deaths caused by drugs, alcohol, assault, suicide, and accidents—in short, anything that is not due to an internal illness)? For the decade 2004-2013, the death rate is 247.4 people per 100,000 population. It is more stable than the all-cause death rate, with a low of 244.7, a high of 249.9, and a standard deviation of 1.7.

With Obamacare extending insurance to 15 million more people, this death rate should fall to 238 per 100,000. The 2014-15 data show the actual reported death rate among U.S. adults, excluding external causes, is … 252.9.

This is equivalent to an excess 11,000 annual U.S. adult deaths relative to the pre-Obamacare steady state trends, and more than 32,000 annual deaths greater than predicted by academic studies quantifying health benefits from improved insurance coverage. It is more than three standard deviations higher than the pre-Obamacare mean mortality, and it has persisted for the two full years, 2014—15, for which mortality data have been compiled. It is not a statistical aberration. Figure 1 shows the data. Whoa.

Figure 1: Time Series of U.S. Adult Mortality, Excluding External Causes

In short, we know much less than we think. We know Obamacare became law, and millions of individuals who were previously uninsured gained new insurance policies, through subsidized private insurance or through Medicaid. We know that academic studies predicted large reductions in U.S. adult mortality following the insurance expansion.

Is the improvement in public health that was assured turned out simply to be another false Obamacare promise?

We know that the same year Obamacare’s insurance expansion provisions took effect, there was a pronounced, and statistically significant, surge in U.S. adult mortality. We know the surge in mortality remains after removing drug-related deaths, and other external morbidity causes, from the statistics. That is all we know. The rest is speculation. But it is fascinating speculation.

Has Obamacare, or some of the secondary effects of Obamacare, actually caused the negative impact in U.S. adult mortality so evident in the statistics? Is the improvement in public health that was assured turned out simply to be another false Obamacare promise, like being able to keep our doctors and health plans, or reducing our health costs?

If any causal relationships are discovered between Obamacare and mortality, there will be profound policy implications. As Sen. Tom Cotton has said, the objective of further health reform is “to help those who were hurt by Obamacare while not hurting those who were helped by it.”

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