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Personal Choices, Not the System, Make for Bad Health Outcomes

The opinions expressed by columnists are their own and do not necessarily represent the views of

Careless About Litter, Careless About Health

Regardless of the future of Obamacare, the most important health decisions wont be made by Congress, or bureaucrats, or insurance companies, or doctors, or hospitals, but by individual Americans with their personal choices and habits.

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This realization hit me with special force as part of the normal neighborhood litter patrol that I’ve described many times on my radio show. For several years, I’ve made it a point to stop the car to pick up garbage that’s been thoughtlessly deposited by the side of the road in the suburban area surrounding our home. This weekend, I especially noticed the prevalence of two particularly obnoxious sorts of trash: cigarette packs and butts, along with fast food wrapping and bags. As I collected the litter in the plastic bag I carry, it occurred to me that the people who were hurting our neighborhood were also hurting themselves. Though no one seriously wants government to crack down further on tobacco or McDonald’s, everyone knows that cigarettes and junk food contribute to bad health outcomes for millions of Americans. Regarding the propensity to litter, it makes sense that those who are careless and sloppy concerning their own bodies will be comparably careless and sloppy when it comes to a public thoroughfare.

On a similar note, those 30 million citizens who neglect their own welfare by failing to purchase health insurance are far more likely to undermine their own health with self-destructive habits smoking, heavy drinking, over-eating, and so forth. Those who are truly too poor to get any sort of private or workplace insurance are already eligible for generous government assistance through Medicaid; in fact, official federal figures suggest that as many as 14 million of the currently uninsured could sign up for Medicaid immediately if they chose to do so. But the same recklessness and irresponsibility that leads people to tobacco-related illnesses and morbid obesity leads people to ignore their own insurance needs, regardless of potentially disastrous consequences.

A Thousand Dead Today Because of Lack of Insurance?

This undeniable association between the uninsured and unhealthy habits helps to explain one of the popular (and utterly misleading) statistics endlessly invoked by big government advocates in the current medical insurance debate. According to apologists for Obamacare, some 45,000 Americans die needlessly every year because they cant get health insurance. The presidents stalwart supporters love to repeat that nearly 1,000 Americans die with no reason every single day because the government fails to provide them with the health insurance they need and deserve.

Any attempt to trace these shocking numbers to a scientific source lead back to an Institute of Medicine study in 2002 involving a dozen medical specialists who estimated that 18,000 Americans died in 2000 because they were uninsured. The journey from 18,000 to 45,000 involves all sorts of questionable twists and turns, involving extrapolations based on reported increases in the numbers of uninsured. In any event, whether the number of avoidable deaths is 45,000, or 44,000 (another frequently cited number), or 22,000 (claimed by Representative Bill Pascrell, D.-N.J. in July, 2009), or 18,000 (the nine-year-old IOM estimate), the whole proposition of thousands meeting their doom through lack of insurance is scientifically and statistically preposterous.

In April of this year, HSR: Health Services Research, published a comprehensive paper by Dr. Richard Kronick of the prestigious medical school at the University of California, San Diego (UCSD). Using statistics from the National Center from Health Statistics (of the federal Centers for Disease Control and Prevention), Dr. Kronick concludes that the Institute of Medicines estimate of tragically unnecessary deaths (or any other study that replicates the IOMs methodology) is almost certainly incorrect.

The difference between Kronick’s study and previous analysis involves the San Diego professors adjustments based on various demographic and health factors, such as smoking status and body mass index. In other words, he concluded that the uninsured suffered a higher death rate because they were vastly more likely to smoke heavily, to eat irresponsibly, to avoid exercise, and to suffer from serious obesity. Comparing a group of insured individuals (who were much more likely to take precautions regarding their own health) with a group of uninsured people (who were far less health-conscious in their behavior) was truly a comparison between apples and oranges (or, perhaps more appropriately, between apples and Big Macs). His examination of decades of federal statistics shows that once you compare truly comparable individuals like assessing death rates among insured smokers vs. uninsured smokers the likelihood of dying evens out. This, in turn, would mean IOMs estimate of 18,000 deaths would drop essentially to zero.

Kronick’s paper suggests that his conclusions stem from the safety net of public hospitals and community clinics providing good enough access to care for the uninsured to keep their mortality rate similar to that of the insured. There would not be much change in the number of deaths in the United States as a result of universal coverage, although the difficulties of inferring causality from observational analyses temper the strength of this conclusion.

Naturally, progressives will dismiss Dr. Kronick’s argument and evidence as meaningless propaganda from the extreme right, but they run into problems with the professors impeccable credentials. He acknowledged that his study didn’t provide the conclusions he wanted, as a left-leaning former Senior Health Care Policy Advisor to President Clinton, and one of the chief designers of the reform proposals known as Hillary Care. His articles have also appeared in the New England Journal of Medicine and the Journal of the American Medical Association.

Superior Care, Even for the Uninsured

Other universally respected scholars in the health care field have reached similar conclusions regarding the alleged dangers of our current health insurance system. For example, the New York Times (not noted as a major organ or right wing opinion) reported on the work of a prestigious demographer at the University of Pennsylvania: A prominent researcher, Samuel H. Preston, has taken a closer look at the growing body of international data and he finds no evidence that Americas health care system is to blame for the longevity gap between it and other industrialized countries. In fact, he concludes, the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis.

The Times summary (September 22, 2009) of Professor Preston’s work highlights many reasons for the contrasting longevity figures between Europe and the United States that have nothing to do with the system of health care: Americans are more ethnically diverse. They eat different food. They are fatter. Perhaps most important, they used to be conspicuously heavy smokers. For four decades, until the mid 1980s, per-capita cigarette consumption was higher in the United States (particularly among women) than anywhere else in the developed world. Dr. Preston and other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries.

He concludes that for all its faults, the American system compares well by some important measures with other developed countries. Preston’s research shows better treatment in the United States for cancer, heart attacks, strokes and hypertension. The U.S. actually does a pretty good job of identifying and treating the major diseases, he concludes. The international comparisons don’t show were in dire straits.

Good News and Better News

While supporters of government health care try to gin up public hysteria about the desperate state of our medical system, accurate analysis actually provides good news and better news. The good news shows that the current health care structure delivers decent outcomes even for the uninsured. The better news indicates that Americans can make further progress in improving their health without waiting for Congress to reach its conclusions about expanded governmental intervention. All available research indicates that when it comes to longevity and disease avoidance, personal decisions play a greater role than public, political decisions. Perhaps the present debate about medical insurance care will encourage the members of the public to take the initiative in improving their own health, without depending on politicians or doctors. There’s no need for delay in cutting down on the cigarettes, sugary soft-drinks, or greasy cheeseburgers with which we trash our own bodies, and in taking responsibility for the attendant butts, soda cans and fast food wrappers with which we deface the neighborhoods in which we live.

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