Social Psychologists Set an Example

Sandra Bem, a feminist social psychologist and the author of gender schema theory, died May 20 at her home in Ithaca, NY, at age 69. Her husband, Daryl Bem, is also a prominent social psychologist. The following is the relevant section of her obituary.

The cause of death was suicide.

When she was diagnosed four years ago with Alzheimer's, she said she would end her life while she still could when the disease became too debilitating to continue.

After years of expensive medical treatments, she stopped all care six months ago and decided it was time to die.

She bought a copy of “The Peaceful Pill Handbook” and chose to take her life with pentobarbital.

The family held a service for her two days before her death.

“Instead of a funeral service, the family met with her last Sunday, a group gathering where we all shared our memories of her and our thoughts and feelings,” said her husband, Darly Bem, 75, also a nationally recognized psychologist. “Everyone was aware that Tuesday was the deadline.”

After spending her last day with Daryl, during which the couple went for a long walk, watched a movie and had dinner, Sandra took the drug at about 7 p.m. Tuesday and died in her sleep.

Thanks are due to the Pittsburgh Post-Gazette for having the courage to publish this information. I suspect some readers were not pleased.

Health Insurance and Mortality, Part 2

Please read Part 1 of this post before continuing.

Not surprisingly, there have been several criticisms of the Sommers, Long and Baicker study. Here are the main ones I've been able to identify so far, and my comments on each.

• It's too good to be true. The New York Times reports that experts are “skeptical of the magnitude and suddenness of the decline” in mortality. According to Dr. Joseph Antos, a health economist at the American Enterprise Institute, “Health care is a much more involved process—you don't just sign up and suddenly get well.” This objection, of course, does not explain the results. These researchers may be overlooking the fact that being without health insurance is a psychological stressor, the removal of which may have immediate health benefits.

• The results contradict those of the Oregon Medicaid study. A 2013 study by Baicker, et al., examined the effects of Medicaid expansion in Oregon using a randomized control group design. (The opportunity to sign up for Medicaid was determined by lottery.) Although this study found economic and psychological benefits of Medicaid, its effects on objective measures of health were disappointing. Blood pressure, cholesterol and blood sugar levels were all lower in the Medicaid group, but the differences were not statistically significant. However, the Oregon study's sample size was too small to detect medically important health benefits. The Massachusetts study has many more particpants. If the same percentage decline in mortality observed in the Massachusetts study had been seen in Oregon, it too would not have been statistically significant. The two studies are not inconsistent. An important strength of the Massachusetts study is its larger sample size. Furthermore, it measured the effects of the entire health reform package, not just Medicaid expansion.

• It costs too much. Using the Sommers, et al., data, Cannon calculated that it cost Massachusetts $4 million per life saved. He argues that this is not cost effective. However, this assumes that the only benefit people received from Romneycare was when it saved their lives. It ignores the many health and quality of life benefits people receive from medical treatments for non-life-threatening illnesses and injuries. What is the value of a knee or hip replacement that allows a person to walk free of pain for 20 years? How do you measure the benefits to a family of avoiding bankruptcy and the loss of their home?

• Massachusetts is different from other states. Massachusetts is “whiter and more affluent” than most other states, but the matched comparison groups control for race and income. It could be argued that Massachusetts has a more effective health care system (more doctors, better-equipped hospitals) than other states. However, a convincing alternative explanation must explain not just lower mortality in Massachusetts, but all the results. Why did the mortality rate change from 2001-2005 to 2007-2010? Wouldn't a better health care system be expected to help people over 65 as well? As Sommers, et al., state in their conclusion:

Although we cannot rule out unmeasured confounders, it is challenging to identify factors other than health care reform that might have produced this pattern of results: a declining mortality rate in Massachusetts since 2007 not present in similar counties elsewhere in the country, primarily for health care-amenable causes of death in adults aged 20 to 64 years (but not elderly adults), concentrated among poor and uninsured areas and not explained by changes in poverty or unemployment rates.

Of course, health insurance is useless if there are no doctors or hospitals in your area. The quality of the health system may have interacted with health care reform to produce a better result in Massachusetts than would be expected in other states. This does not explain away the results, but it may limit our ability to generalize from them.

• More research is needed. This cliché is, of course, trivially true. However, it is unrealistic to expect definitive studies of effects of the Affordable Care Act (ACA), since it is being implemented simultaneously in all 50 states. There are no experimental and control groups, only before and after comparisons, the results of which can easily be dismissed as caused by other changes taking place in society at the same time. About the best we can expect will be comparisons between states that do or do not expand Medicaid. (Pennsylvanians will be happy to know that, thanks to Governor Tom Corbett and our legislature, future researchers will be counting the number of excess deaths in our state.) However, states that are not expanding Medicaid are already known to differ both economically and politically from other states. And while Medicaid expansion is an important provision of the ACA, it is only a part of it.

In short, the Sommers, et al., study may be the best that is available for the foreseeable future. Even conservative critics of health care reform are granting it grudging respect.  Megan McArdle stated, "(A)fter yesterday's report, I've revised the probability of 'huge benefits' [from health care reform] upward, and you should do the same."

You may also be interested in reading:

Health Insurance and Mortality, Part 1

Big News From Oregon:  Not All of It Good

The Coverage Gap:  The Real Failure of Obamacare

Romneycare:  The Bottom Line

Health Insurance and Mortality, Part 1

In 2006, Massachusetts implemented the country's first comprehensive health care reform (“Romneycare”). It made health insurance mandatory for nearly all citizens, expanded Medicaid to cover people earning up to 150% of the federal poverty level (FPL), and provided health insurance subsidies for people with incomes up to 300% of FPL. It became the structural model for the Affordable Care Act (ACA). A previous study showed that Massachusetts residents reported themselves to be in better health following the implementation of Romneycare. A new study out this week shows that health care reform significantly reduced the mortality rate in Massachusetts compared to nearby states. This is the bottom line in health care research. It's good news not only for the ACA, but for single payer advocates as well, since single payer would further expand the number of people covered by health insurance and would presumably reduce the red tape and out-of-pocket costs that keep some people from using health care.

The study, by Drs. Ben Sommers, Sharon Long, and Katherine Baicker, is a quasi-experimental design. It lacks an important feature of true experiments—random assignmnent of participants to conditions—but attempts to compensate for this by using a matched comparison group that controls for most plausible alternative explanations. In this case, the experimental group was the citizens of Massachusetts. Each county in Massachusetts was matched with a comparison county drawn from a nearby state. The counties were matched for age distribution, race and ethnicity, poverty, income, unemployment, lack of health insurance, and their existing mortality rate. The authors compared the mortality rates of adults under 65 from 2001-2005 (prereform) to 2007-2010 (postreform). Here are the results.

• Mortality in Massachusetts declined 2.9% relative to the comparison group. This is equivalent to 8.2 deaths per 100,000 people, or one death prevented for every 830 people who obtain health insurance. The New York Times calculates that a national 2.9% decline in mortality among adults under 65 would translate to about 17,000 lives saved per year. Harold Pollack claims that the number is as high as 24,000 per year.
• Mortality “amenable to health care,” i.e., from causes such as cancer, heart disease and diabetes, declined 4.5% relative to the control group. Mortality from causes not amenable to health care, i.e., auto accidents, was unchanged. See the chart below.
  
  

• Mortality among people over 65 was unaffected. This is to be expected, since senior citizens already had Medicare.
• Reductions in the mortality rate were greatest among counties with the lowest incomes and the lowest rates of insurance coverage prior to reform.
• As you would expect, the study also found significant increases in insurance coverage, access to medical care, and self-reported health in Massachusetts compared to the comparison group.

As health care expert Austin Frakt has noted, this study constitutes the strongest evidence yet that having health insurance can save your life. Nevertheless, the study is not without its critics. I will look at some of those criticisms in Part 2 of this post.

You may also be interested in reading:

Health Insurance and Mortality, Part 2

Big News From Oregon:  Not All of It Good

The Coverage Gap:  The Real Failure of Obamacare

Romneycare:  The Bottom Line