Tuesday, August 3, 2010

Illness and Bankruptcy: Which Causes Which and Why Can't We Be More Humble About Not Really Knowing?

In a prior post, the Disease Management Care Blog described the curious evaporation of arguments about the merits of universal coverage as a cost-saving benefit of the Affordable Care Act (ACA). True to form, that assertion went unmentioned by HHS Secretary Sebelius in yesterday's PBS NewsHour appearance, who instead used the appearance to murmur nostrums at Judy about the voters' lack of education and spin a repackaged report about Medicare's solvency. It's so clear, isn't it? So... black and white. We're right, they're wrong.

When it was still in political play, another argument favoring the ACA was the startling finding that 62% of bankruptcies nationwide had their roots in medical causes. Removing the threat of being one illness away from losing your job and becoming destitute was certainly a compelling argument in favor of reform. The methodologically rigorous DMCB had its doubts about the not-so-small differences between causality and association, but it seems no one in Congress was paying attention.

Well, Hat Tip to Healthcare Economist Jason Shafrin who continues to pay attention and linked this article on the health impact of mortgage foreclosures. While popular opinion would have you believe illness causes economic woes, this article suggests the opposite is true: that having economic woes causes illness.

So which is it?

There is research, for example, that argues that there is a causal link between stress and heart rhythm problems, as well as drug abuse relapses and unremitting fatigue. The DMCB suspects that, when it comes to stress, these and and other medical conditions are probably bi-directional and self reinforcing. The DMCB recalls seeing many patients in its clinic who were caught in a downward cycle of economic, emotional and medical distress. In its real world, it was impossible to unravel what was causing what: the dumbass hubby's behavior, the recurrent migraines, being unable to maintain employment, lack of child care, not being able to pay the co-pay and then failing to pay rent.

What the DMCB learned about was the remarkable resiliency of many unseen average people who managed to get through it. It also learned to be humble when it comes to understanding the links between health care and economic well-being. Come to think of it, the same lesson undoubtedly applies to all those other corners of the ongoing health care debate. Unfortunately, that'd mean not changing the subject and saying stuff on PBS NewsHour like we think and hope we're right, and we believe they're wrong and we know there limits to the science that undergirds our decision making.

In this summer of our political discontent, that seems very unlikely. That's why it makes sense to read blogs like Healthcare Economist and the DMCB in addition to watching the NewsHour.


The Notwithstanding Blog said...

If I recall correctly, even the medical bankruptcy research was decidedly underwhelming. Going back and re-reading the abstract has confirmed that inkling on my part.

Their definition of "medical bankruptcy" is unnecessarily broad. For any household with more than $5000 in medical debt it was *assumed* that the medical debt (as opposed to the other debt involved, even if of greater magnitude) was what drove the bankruptcy.

To the extent that this study has been used to argue for the PPACA, it's worth noting that the bankruptcies caused by lost income from illness won't be avoided under the new regime either.

Megan McArdle has posted on this more extensively, but this comment is just from re-reading the abstract.

[also, OpenID authentication seems to have been broken here for quite some time...]

Phil 314 said...

Well someone risks bankruptcy in this. I fear it may be more than a few homeowners

On a separate note, i could only watch a portion of the Sebelius interview. Her public pronouncements have been consistently disappointing (i.e. "you'll learn to like it", "its the Republicans", "its the Insurance companies") I guess cheer leading is part of the job description.