Update on Health Studies

In a February 10 article for The Denver Post, Katy Human wrote, “Children with health insurance, studies have shown, are less likely than uninsured kids to end up in emergency rooms, more likely to get key vaccinations and less likely to be absent from school.”

My immediate thought upon reading this claim is that it doesn’t indicate the causal relationship. So I asked Human about this, and she replied that the studies “control for factors such as income and education of parents.” I wanted to check this and see what else the studies have to say, so I asked Human to provide me with the citations. On February 21 Human sent me a list of studies. Linda Gorman looked into the studies, and then Dave Kopel also took an interest in them. He checked into the studies originally mentioned by Human, looked at other studies as well, and wrote up his results for the March 8 Rocky Mountain News:

None of five studies Human cited after the fact support her article’s statement about what “studies have shown” regarding the effects of insurance on emergency room use, vaccinations and school absences. Indeed four of the five studies she cited do not even address those topics (Cousineau, Medical Care, 2008; Skinner, BMC Health Services Research, 2007; Ward, CA: A Cancer Journal for Clinicians, 2008; Morbidity & Mortality Weekly Report, Sept. 7, 2007).

One study cited by Human was relevant, and it directly contradicted her article’s claim. The study looked at the effect of providing SCHIP coverage (subsidized insurance for children whose families have too much income to qualify for Medicaid). Emergency room usage “did not change,” the study found. (Szilagyi, Pediatrics, 2004).

… [Later] Human supplied two more citations to substantiate her article’s claim about emergency rooms. One of the studies was irrelevant, a 2002 Centers for Disease Control and Prevention report which reported no data about frequency of emergency room use for the insured and uninsured.

Human supplied another study which did support her claim. William Johnson and Mary Rimsza investigated Yuma County, Ariz., and found that uninsured children there use emergency rooms more often. The Johnson and Rimsza article, published in Pediatrics in 2004, forthrightly acknowledged that four other studies have found that taxpayer-funded insurance for children actually increases emergency room usage, and a fifth study finds that there is no effect. Johnson and Rimsza suggested that results were different in Arizona because the state’s medical welfare program links recipients to pediatricians, and having a pediatrician drastically reduces ER visits for both the insured and uninsured.

Of course, a broad correlation between lack of insurance and emergency-room visits is still possible for at least a couple of reasons. First, some people without insurance are more likely to visit the emergency room — which by law must provide care for no compensation — for care that is less-expensively offered at the regular doctor’s office or at lower-cost clinics. Second — and this point also applies to vaccinations and school attendance — parents who purchase health insurance for their children may be more likely to be employed, make more money, have a higher level of education, live in safer neighborhoods and homes, encourage healtheir lifestyles for their children, and insist on regular school attendance. This is a statement only of anticipated averages; many model parents are less wealthy, and many parents pay for their children’s health care out of pocket rather than through insurance.

However, the thrust of Human’s article was not to reveal correlations regarding health insurance, but to advocate more tax funding for health programs. Everyone can agree that it would be good for more parents to buy health insurance for their children (though insurance as such should move in the direction of high-deductible policies with routine expenses paid out of pocket). But expanded tax subsidies create all sorts of problems with incentives, such as by encouraging some parents to drop private insurance in favor of tax-funded welfare.

It’s quite a leap from “insurance for children is good” to “politicians should expand their control of medicine.” Indeed, as Lin Zinser and Paul Hsieh argue, the proper way to make health-insurance more affordable is to repeal the existing political controls that have made it so expensive.