The take away message for me isn’t necessarily that the RAND HIE is flawed or is perfect, but that reasonable people can debate the degree of reliability of the results. That’s true of any study. Just because it had a randomized experimental design does not in and of itself mean that the RAND HIE results are any more or less correct than those from any other study. It all depends on the extent of the known issues with the data and how they’re handled. A well done observational study can be as or more informative than a randomized trial.

I also recall a debate about panel attrition in the Rand study. The rate of attrition wsa tiny compared to most panels. However, it was large enough that it could have covered differences in mortality. Again the point is that mortality is rare. Missing the deaths of a fraction of a percent of experimental subjects can totally change the conclusion. More subjects than that vanished- were not tracked — had health outcomes which couldn’t be assessed. Under the implausible assumption that all such subjects died, one would conclude that less generous health insurance had a huge huge effect on mortality (the low rate of attrition was higher for those who received stingy insurance). Under the implausible assumption that they were no more likely to be dead that non drop outs the RAND team concluded that less generous health insurance had approximately no effect on mortality. Given the data, depending on the assumptions, the result could be anywhere in between.

The best and the good enough. The RAND study might have been the best attempt to prevent panel attrition in human history. Arithmetic says it might also not have been good enough to get a reliable estimate of the effect of the generosity of health insurance on mortality.

Also there was a definite statistically significant and large effect of generosity of coverage on the rate of dropping out of the financial aspects of the study (returning to pre-study health insurance — this is different from panel attrition ). This probably surprised the Rand team, since it was never economically advantageous to drop out of the financial part.

It is obvious from that data that subjects delayed health care, dropped out and then obtained the health care (the health care demanded by dropouts was very low especially shortly before they dropped out — this is true for ambulatory care but not hospital care for those who had stingy cover of abulatory care but generous coverage of hospital care and vice versa). The effect of delaying care on both final outcomes (measured) and total health care spending (not evaluated) are minor. The effect on spending while covered by the experimental insurance is large. This pattern, which is very clearly in the data, can explain the RAND results and prove that they are completely uninteresting.

In response to criticism, the RAND team analysed the drop outs (decades after the study was conducted). They assumed that health care utilization decisions depend only on current insurance — that the fact that I will be insured tomorrow has no effect on whether I seek care today. This assumption is obviously totally utterly insane. Their claims absolutely are as reliable as that assumption.

The RAND study is the best ever. It is also just not good enough to tell us anything useful.

I’m just a commenter so i don’t have to provide links. This is a good place to start http://tinyurl.com/yjvcms2 . You have to understand what they are saying to understand that my description ((above) of the absolutely absurd assumption was made by the RAND team is absolutely accurate.

They get saner as they grow up, right?

@HC novice – One time cost cuts won’t affect the rate of cost increases. But adjustments to payment methodology and incentives can. I think it is possible to harness market mechanisms in this effort. Nevertheless, at this time none of the politically dominant stakeholders will permit any form of cost cutting for reasons Nichols expressed. If one is willing to overlook that reality then it makes sense to consider approaches that don’t start with increasing coverage.

Steve

I emailed Klein earlier today. I’ll keep you posted on any response.

However, his conclusion is based on the assumption that this is the form that cost cutting will take. If, on the other hand, cost cutting involves more market-driven approaches such as greater price transparency and allowing consumers to purchase a greater share of their own medical care (through any number of financing mechanisms), thus applying downward pressure on provider pricing, coverage expansion would occur naturally. That is, coverage expansion for the uninsured, under-65 population that either forego insurance by choice or are forced out of the market by increasingly expensive plans will be able to finance their own care more easily.

Cutting Medicare/Medicaid reimbursement rates by 5 or 10% may slow federal spending, but it won’t affect the underlying growth of medical costs, which, it seems, is the real impediment to expanding coverage.

Seriously, ask Klein. It is a good question. Throw him an e-mail and cite this discussion if you like. Then bring it up in a chat. Please let me know what you learn.