The topic of universal health insurance is a controversial one that seems to show up with increasing frequency in the political sphere. Though the arguments typically revolve around the costs and the number of people covered, it's unfair to bring up these concerns without first addressing the science behind universal health insurance. In my first-ever blog entry, I wanted to give an overview of the topic. It's a bit long-winded but I hope you stick with it and post any thoughts that you may have.

Does having health insurance improve your health?

To answer this question, you would need to do an experiment. In this experiment, you would need to take a number of sick people with and without insurance and follow them to see how their health changed over time. At some point, you would give insurance to those who are uninsured, and see if it made any difference in their health. This sounds like a difficult study to undertake, yet it is one that was conducted by physicians at Harvard and published in the Journal of the American Medical Association in December of 2007. Universal health insurance does exist in this country for a subset of our population, in the form of Medicare. Every adult in this country qualifies for Medicare Plan A merely by turning 65 years of age (with a few rare exceptions). In this study, the doctors compared the health status of insured and uninsured people before and after the age of 65 to determine if there was any impact of acquiring Medicare, a form of universal health insurance. What did they find? "Before age 65 years, summary health scores worsened at a greater rate for uninsured adults than for insured adults and were significantly worse at age 65 years. After age 65 years, however, this adverse trend differentially improved for previously uninsured adults such that summary scores after age 65 years indicated near maintenance of health for previously uninsured adults but continued deterioration for previously insured adults." Based on this data, it is clear that acquiring health insurance has a health benefit.

Even if you acknowledge this benefit, you may rightly wonder if it applies to you. Let's say you're a successful small business owner who feels financially secure enough to not buy private health insurance.

Does having an increased income make it less necessary to get health insurance from a health standpoint?

Again, this question is best answered with an experiment, and this study has also been undertaken by physicians at Yale who published their results in the Journal of the American Medical Association in January of 2007. For different income levels, they compared uninsured and insured patients in their likelihood of getting preventive screening and in specific measures like cholesterol and diabetes management. Unsurprisingly, they found that having a greater income does improve a handful of health care measures. However, they also found that at every income level (even for people making more than $75 thousand a year), there was a statistically significant difference in almost every health measure when comparing the insured to the uninsured. So even if you're a successful professional who has the money to pay for health care, you are more likely to have worse health measures and are less likely to seek breast, cervical, and colon cancer screening if you are uninsured than if you were insured.

There is good evidence to demonstrate a health advantage in providing a population with health insurance. However, aren't there other ways of improving the health of the uninsured? What if we were to build special clinics dedicated to treating people who lack insurance?

Are safety net clinics an effective way of providing health care to the uninsured?

The Urban Institute published a paper in 2002 comparing safety nets in thirteen states. Though there are uninsured people in every state, different states have differing amounts of resources available to deal with their respective uninsured residents. One would expect that states with fewer uninsured people and greater resources would be able to provide better health care access than states with a greater population of uninsured people and fewer resources. This holds true to a degree. When measuring if patients had a usual source of health care, the difference between the most and least vulnerable states was roughly 10 percentage points. However, if you compare the difference in having a usual source of health care for uninsured and insured patients, this difference is 20% in every single state studied and up to 50% in California, Michigan, and New York. Although having a strong safety net for uninsured patients is beneficial in improving health care access for a population, it is merely a drop in the bucket when compared to providing health insurance to that population.

So what has our health policy been over the last 6 years? In 2002, President Bush launched the Health Centers Initiative to create Federally Qualified Health Centers (FQHCs). These are federally funded clinics that provide care to the uninsured. There are a long list of requirements that must be met for a clinic to receive FQHC status. In fact, the requirements are so stringent and resources so limited that in the state of Michigan, there are a total of 5 such clinics. As you may imagine, communities that are successfully able to operate a FQHC are tremendously benefited from them. There is no doubt that there are uninsured people who are greatly impacted from Federally Qualified Health Centers. But ultimately, these clinics are a means of bolstering safety nets, which have been shown to have a limited impact on improving public health care access.

In contrast, numerous studies have already demonstrated a significant health benefit in having health insurance. From a policy standpoint, it makes sense to implement a proven and effective intervention when addressing the issue of public health. The science behind universal health insurance is sound. Who will provide it? Who will pay for it? These are tough questions that will need to be answered. However, we cannot dismiss universal health insurance as a purely fanatical concept with no pragmatic value.