“People respond to incentives, although not necessarily in ways that are predictable or manifest. Therefore, one of the most powerful laws in the universe is the law of unintended consequences.” -SuperFreakonomics
By Jerry A. Boggs | Updated May 26, 2013 | First version published in 2011
Most of us drive our vehicles very carefully, even though we have insurance to cover accidents.
But suppose you had no insurance. (I periodically went without it as a young adult earning a pittance.) Think how much more carefully you’d drive! And how much more slowly. Yes, you would. And you’d likely drive less. (And maybe walk more and become healthier for it.) One thing’s for sure, far fewer motorists would text while driving!
For many people, I suspect, the more auto insurance they have and the less their deductible, the more they might tend to drive and the faster and less guardedly. (Keep comparing how you’d drive without insurance.) That means more accidents in which people are killed and injured. Although insurance is a wonderful thing — preventing bankruptcies and poverty and bestowing peace of mind — it might have the unintended consequence of causing more accidents and more deaths and injuries than if no one had insurance.
In a report on how to fight pandemics, the March 2012 Discover magazine says the secret to fighting them is “knowing their real cause: disease factories built by people. Ironically, hospitals turn out to be highly efficient disease factories. They allow the proliferation and spread of dangerous germs among patients, and the evolution of those germs to extreme levels of virulence.”
In that same vein, the PBS documentary “Money & Medicine,” which aired September 26, 2012, says 98,000 deaths result from medical mistakes.
Yet 12 years ago the news from the Journal of the American Medical Association was even more alarming:
“America’s healthcare system is the third leading cause of death in the U.S., causing between 230,000 and 284,000 fatalities per year, behind only heart disease and cancer.”
The report didn’t say the third leading cause of death is poor health. It said the healthcare system itself. In other words, our country’s third leading cause of death is the legions of good-intentioned doctors, nurses, and others whose ultimate duty is to help us avoid death.
JAMA provides a breakdown of the deaths caused by healthcare (for other breakdowns, go here):
- 12,000 deaths per year due to unnecessary surgery
- 7,000 deaths per year due to medication errors in hospitals
- 20,000 deaths per year due to other errors in hospitals
- 80,000 deaths per year due to infections in hospitals
- 106,000 deaths per year due to negative effects of drugs* (See also the Nov. 19, 2012, report by Dr. Sanjay Gupta, CNN’s chief medical correspondent.)
“Pharmaceutical drugs are 62,000 times more likely to kill you than supplements.” -Dr. Mercola
To the JAMA list we must add the figures cited in September 2012 by Shannon Brownlee, Acting Director, Health Policy Program, New American Foundation: “The estimates are that tens of thousands of cancer deaths are being caused by medical radiation.” (CT scans, MRIs, etc.)
Then add the nearly 200,000 patients that may be killed each year by blood clots following surgery or illness, the leading cause of preventable hospital deaths in the U.S., according to David Goldhill, author of the article “How American Healthcare Killed My Father” and the book “Catastrophic Care, released January 8, 2013, citing a report in The Wall Street Journal. (Watch Goldhill’s video.)
It’s almost enough to make one ask, “Why don’t we drop our health insurance and stay away from doctors?”
Of course, I’d never advocate such a position for all the obvious reasons. But if no one had health insurance, lots of things could happen, both bad and good. A good:
In 2008, shortly after the economic collapse, I was watching a CNN reporter interview a woman on the street. She had just lost her job. The reporter asked how she was coping.
“Along with my job, I lost my health insurance,” she said [I paraphrase]. “Now I have to really be careful to watch what I eat, lose weight, exercise, and take better care of myself.” I got the impression that while she had health insurance, she tended to be a bit reckless with her health, figuring she was covered if she got sick.
Some people are like that when they feel they have a safety net under them. Maybe many people are. That’s because, according to a Slate.com article, “Insurance is also the source of what economists call ‘moral hazard,’ where those who are protected against the consequences of their actions take greater risks than they otherwise would.” “The Oregon Health Insurance Experiment” adds: “Although health insurance is expected to improve health through increases in the quantity and quality of health care, it is also possible that by reducing the adverse financial consequences of poor health, health insurance may discourage investments in health and thereby worsen health outcomes.” In the May 5, 2013, Business Insider, Joe Weisenthal says a study done by the RAND Corporation:
But the study also tracked the health outcomes of each group, and there the results were more surprising: With a few modest exceptions, the level of insurance had no significant effect on the participants’ actual wellness.
In that study, could the moral hazard have mitigated the benefit of insurance on wellness, since the well-insured tend to be less vigilant about watching their health than the poorly-insured and the uninsured?
(The number of people affected by the moral hazard can depend on the type of moral hazard; i.e., private insurance vs. a government bailout, which is also insurance. And the level of legitimacy or validity one gives the moral hazard may depend on one’s political leanings: Liberal Times columnist Joe Klein may not think the moral hazard is triggered by health insurance for individuals, but he apparently does think it’s triggered by government bailouts to big banks: “Sadly, neither President Obama nor Mitt Romney have addressed the ‘moral hazard’ that accrues from having banks that are too big too fail….” See a New York Times argument. There needs to be a non-partisan study of the real, determinable effects of moral hazard.)
Without health insurance, CNN’s interviewed woman became like the driver without car insurance.
And what if doctors had no liability insurance to protect them from being sued for malpractice? Would they, too, become like the driver with no car insurance, the result being more-careful doctors and hence less malpractice, which is to say less injury and death to patients under their care? (Without liability insurance, no doubt we’d have fewer doctors, and healthcare would be harder to get — but apparently that might not be entirely bad!)
Enter President Obama’s Affordable Care Act (ACA), whose aim is to get almost everyone insured and require millions to buy insurance.
A lot of young adults currently elect to have no health insurance (as I once did) because of its cost, or because they want to save money while they’re young and healthy. Once forced to buy insurance under ACA, many of these healthy young adults can, I imagine, be counted on to frequently see a doctor for minor things merely “to get my money’s worth.”
“I see too many patients who aren’t sick.”-Dr. Marc Siegel, Fox News, Nov. 8, 2012
How many more people, because they have insurance, will pay less attention to diet and exercise like CNN’s woman on the street, and develop medical problems (such as diabetes) that require visits to the doctor that they would not have had to make while uninsured and cautious?
In 2014, ACA will bring into the healthcare system an estimated 32 million newly insured people, mostly young adults — though an astonishing 26 million will be left out, meaning the new universal healthcare is not so universal after all — who according to economic studies “will try to consume twice as much medical care as they have been,” and bring countless others into it more often. It’s obviously supposed to do that, since Mr. Obama rightly wants to spread the health around.
He also wants to spread Medicaid around to include millions of uninsured. Yet according to large study by the University of Virginia, surgical patients on Medicaid, the expansion of which President Obama himself described as putting “more people in a broken system,” are 97% more likely to die than those with private insurance and 13% more likely to die than those with no insurance at all.
And let’s not forget that every day for the next 18 years, 10,000 Baby Boomers, whose health on average is very poor and getting worse, will reach age 65 and become eligible for Medicare. Many Boomers will seek healthcare services before losing their employer insurance, and many others who’d had no insurance and had put off healthcare will put it off no longer.
Moreover, we have a fast-growing obesity epidemic (chart), especially among the young, for whom obesity, a condition worse than smoking, has jumped from 9% of the adolescent population in 2000 to 23% in 2008, and threatening to overwhelm our health care system. The main threat is the costly diabetes that is often obesity’s side effect; some people call it diabesity.
We also have this problem:
More than four in 10 U.S. physicians said they were emotionally exhausted or felt a high degree of cynicism, or “depersonalization,” toward their patients, said researchers whose findings appeared in the Archives of Internal Medicine.
“The high rate of burnout has consequences not only for the individual physicians, but also for the patients they are caring for”…. -Reuters, August 21, 2012; more at Medscape.com in a report dated March 28, 2013
Six in 10 physicians said it is likely many of their colleagues will retire earlier than planned in the next 1 to 3 years. -Every Day Health, March 21, 2013
Finally, “one flaw in the Affordable Care Act,” says Business Week, “is that by prohibiting insurers from taking health risks into account in setting rates, it gives people no incentive to lower their premiums by losing weight….”
The upshot is that millions more will interact with the healthcare providers who are, according to JAMA, our nation’s third leading cause of death.
These providers, unless there is a huge increase in their already insufficient number, will be stressed by the increased demand for services. Their error rate is likely to rise.
Efforts, which may be thwarted by dubious funding, are underway to deal with the insufficient number of primary care physicians: “As Obamacare Looms, New Medical Schools Open To Address Doctor Shortage.” (See also this Bloomberg report.)
They’d better hurry. The number of doctors working part-time is increasing at an alarming rate: “In 2011, 22% of male physicians and 44% of female physicians worked less than full time, up from 7% of men and 29% of women from Cejka’s 2005 survey.”
(See also: “We don’t need more doctors.”)
A monkey wrench has already appeared in the efforts to deal with the U.S. shortage of 91,000 doctors by 2020 (according to the September 2012 Wired magazine): The Association of American Medical Colleges “worries that the funding may soon not be there to support residency programs for this larger number of medical school graduates in the next two to three years. The Balanced Budget Act of 1997 capped the number of available slots for residents coming out of medical school as part of the law’s reduction in spending on Medicare, which largely funds residency programs.”
Once Obamacare is fully up and running, could our healthcare system then become, according to the audio book “Killer Cure,” the second leading cause of death? Or even, in the worst of ironies, the first?
Do we really know what we’re doing?
* Source list regarding prescription drug abuse, compiled by Mercola.com:
- Morbidity and Mortality Weekly January 13, 2012 / 61(01);10-13
- CNN November 14, 2012
- Congressional Testimony May 24, 2011
- CNN November 14, 2012
- NYTimes.com April 20, 2007
- University of North Carolina April 25, 2011
- CNN November 15, 2012
- CNN November 15, 2012
- JAMA. 1998 Apr 15;279(15):1200-5.
- Altern Med Rev. 2010 Dec;15(4):337-44.
- Arthritis & Rheumatism, Volume 54, Issue 11, pages 3452–3464, November 2006
- The Journal of Neuroscience, 6 April 2011, 31(14): 5540-554
- Psychol Sci. 2006 Dec;17(12):1032-9.