Nicholas Kristof’s Appeal to Emotion and the ACA

In yesterday’s New York Times, columnist Nicholas Kristof argued in an editorial that the biggest problem with the Affordable Care Act is not its online exchange glitches. Instead, Kristof wrote, the biggest problem is that the ACA was not implemented soon enough, so Americans are suffering as a result.

Kristof’s column deals specifically with the story of a 47-year-old truck driver/repairman from Eugene, Oregon. The driver, whose name is Richard Streeter, lost health insurance coverage in 2008 when his employer dropped it, and due to chronic smoking was unable to afford any of the plans available on the individual market. As a result, Streeter avoided doctor’s visits as much as possible. By the time he noticed blood in his stool and got the appropriate diagnosis from a qualified doctor, he had developed advanced colon cancer.

Kristof uses Streeter’s story as a jumping off point to discuss the U.S. health care system, and comes out in favor of the Affordable Care Act:

So, to those Republicans protesting Obamacare: You’re right that there are appalling problems with the website, but they will be fixed. Likewise, you’re right that President Obama misled voters when he said that everyone could keep their insurance plan because that’s now manifestly not true (although they will be able to get new and better plans, sometimes for less money).

But how about showing empathy also for a far larger and more desperate group: The nearly 50 million Americans without insurance who play health care Russian roulette as a result. FamiliesUSA, a health care advocacy group that supports Obamacare, estimated last year that an American dies every 20 minutes for lack of insurance.

Before I move any further, I’d like to point out that Streeter’s story is, indeed, tragic and heartbreaking, as is Kristof’s story about his college roommate Scott Androes. (I believe I have seen him discuss Androes before in a similar context but I can’t seem to find the link at the moment). The fact that many Americans go without health care is, to me, one of the biggest problems in our society today, which is why I devote so much time to reading and writing about all of these issues every day. Where I would disagree with Kristof, however, is his interpretation of the most efficacious solutions to the situation we’re facing, and his seeming lack of familiarity with the specifics of the general conversation on health care.

For one thing, Kristof implies that Republican opposition to the Affordable Care Act is a function of a lack of empathy for a large and desperate group of nearly 50 million people who go without health insurance. I wrote yesterday about the why it’s important to really understand the numbers you use in the health care debate, and this statistic is actually no different. Kristof gets the number from a Kaiser Family Foundation primer called “Key Facts about the Uninsured Population,” but the number is generally quoted as anywhere between 40-50 million in conversations on our health care system. If you break statistics such as these down, however, the picture begins to look a little different.

Although it’s true that nearly 50 million people are uninsured, Kristof’s claim that they’re all playing Russian roulette with their health care is exaggerated. A May 2003 CBO paper makes a claim similar to that of Kristof and KFF: that in 2003, 42.6 million Americans went without health insurance–at a specific point in time during the year. Between one-half and two-thirds of those people did have health insurance at other points in 2003, and a full 45% of them went without health insurance for fewer than four months.

How can this be? It’s simple. The statistic Kristof is citing makes no distinction between the temporarily uninsured and the chronically uninsured. The temporarily uninsured are those who are between jobs and are simply experiencing a brief gap in employer-based coverage until they begin to work with their new employer. A CBO paper that came out two years later actually found even more striking results:

The 2005 CBO report said that the majority of the uninsured are either illegal immigrants (as many as 12 million), or earn between $50,000 and $75,000 annually (8.3 million), or earn more than $75,000 a year (8.74 million) and elect not to purchase health insurance. That adds up to 29 million of 46 million total.

Of the rest, approximately 8.8 million are without insurance for four months or less and then return to the ranks of the insured. That leaves some 8.2 million Americans the Kaiser Family Foundation’s analysis describes as “chronically uninsured.”

I’m sure these numbers have shuffled somewhat in the past decade, but the point remains the same: the number of Americans who lack health insurance at any point in time during a calendar year is not a totally accurate proxy for the number of Americans who are not able to afford access to health care. This is not at all to say, of course, that 8-10 million people who are in that boat aren’t a concern or that we shouldn’t be trying to help them, but rather just a call for clarity in the way we are using statistics– especially those that appeal to our emotions.

Whether or not there are 10 million or 50 million chronically insured people in America, however, makes little different to someone like Richard Streeter. The fact that he alone is chronically uninsured is all that is relevant to him, so let’s take a closer look at this part of Kristof’s column. In telling Streeter’s story, the author includes the detail that Streeter decided not to purchase health insurance because it was too expensive. The implication here is that the high cost of health insurance is a flaw of the current system that will be remedied under the Affordable Care Act.

If you look at the premiums in Oregon, however, a different picture begins to come into focus. If you go to Forbes.com, for instance, you can view an interactive online map that attempts to predict the average change in health insurance premiums across a number of demographics by state. (You can find the methodology that went into creating the values displayed on the map here ). Oregon is one of the states for which full data was available to the creators of the interactive map. For a male Oregonian who is about 40 years old, the map lists a pre-ACA average rate of $144 per month and a post-ACA average rate of $178 per month–an increase in cost of 24%. Kristof’s article doesn’t indicate whether or not Streeter is eligible for premiums subsidies under the ACA but, if he isn’t–and if the values on the map are reasonably accurate–then the ACA could actually make it even less likely that he would have purchased health insurance on the individual market.

Finally, Kristof cites a number of different sources as evidence of the inferiority of the US health care system:

The Institute of Medicine and the National Research Council this year ranked the United States health care system last or near last in several categories among 17 countries studied. The Commonwealth Fund put the United States dead last of seven industrialized countries in health care performance. And Bloomberg journalists ranked the United States health care system No. 46 in efficiency worldwide, behind Romania and Iran.

The Institute of Medicine and National Research Council report that Kristof links to is a 3 page long document that briefly summarizes the findings of a larger study. The summary shows that the US compares poorly with 17 other industrialized nations in a number of categories related to health care. The problem with using this as evidence for Kristof’s argument is that few of these areas–which include infant mortality and low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted infections, AIDS, drug-related death, obesity, diabetes, heart disease, chronic lung disease, and disability–can be viewed as variables that track solely alongside insurance levels or system of health care. Many of those categories may be more affected by demographics and the realities of living within certain socioeconomic environments than they are by national health care systems, and some–such as homicides and obesity–seem to have almost nothing to do with health insurance.

What is even more interesting is that the same report also notes that the US health care system outperforms other countries in areas that are more directly tied to the provision of health care, such as treatment of cancer, cholesterol levels, and blood pressure. On top of that, the report even argues that US health disadvantages in comparison with the rest of the world cannot be explained solely by health and wealth disparities.

The Commonwealth Fund study that Kristof cites has been trumpeted by the press, but it has serious flaws as well. For one thing, it is based not on hard data but on surveys that make no attempt to control for societal differences between nations ( see a good critique of the Commonwealth Fund study along these lines here ). On top of that, its methodology is seriously questionable, and equal weighting is given to factors as different as a patient-reported infection contracted during a hospital stay and whether or not doctors employ automated systems to remind patients of their appointments! ( Click here for more ). And I probably don’t even need to go into the problems with citing Bloomberg journalists as a strong authority on health care systems, but that ranking is based solely on expenditures versus life expectancy.

In short, each of these sources either does not support the conclusions that Kristof draws, or uses flawed methodologies and irrelevant data insofar as it does. Somehow, this does not prevent Kristof from concluding that the reason the United States ranks poorly when compared to other nations is a direct result of the uninsured’s lack of coverage:

The reason is simple: While some Americans get superb care, tens of millions without insurance get marginal care. That’s one reason life expectancy is relatively low in America, and child mortality is twice as high as in some European countries. Now that’s a scandal.

See yesterday’s post for information on why life expectancy and child mortality are not relevant in ranking health care systems on an international scale. (As for Kristof’s claim that lack of insurance is the “simple reason” behind America’s poor ranking compared to other nations in these studies, he is right that the uninsured typically incur massive costs and that treating them in the inefficient ways we do is a source of waste in the system).

As Kristof explains, Streeter has signed up for health insurance under the Affordable Care Act despite his pre-existing condition, which will surely help him in the difficult battle he is preparing to face against colon cancer. Although his story is devastating, and while we all would certainly wish him nothing but the best, Kristof’s use of it as an appeal to reader emotions in defense of the ACA is severely lacking. At the end of the day, I think that the biggest problem with Kristof’s article is not his flawed use of dubious sources or his lack of familiarity with the national conversation about health care in general, but rather that he is simply begging the question.

In other words, Kristof, like many others, argues that we need the ACA because people are hurting due to the high cost of health care. What he is assuming, however, is that the ACA is effectively going to lower the cost of health care, and he mistakes nominally low costs that some individuals may find on the exchanges with the actual cost of health care nationwide. If the latter increases under the ACA, so will the former, and I’m not sure that any of the problems Kristof raises in the column will truly have been solved.

I’ve heard that John Rawls said that if you think a great philosopher has made an obvious, crude mistake, assume it’s more likely that you missed something. I’m not comparing the Republicans to great philosophers, but there are a lot of very intelligent people who are against the ACA and in favor of more free market reforms. (It’s worth noting that Kristof cites none of them and does not even attempt to articulate their arguments). What he’s missing is that these people aren’t stupid or callous; they simply believe that for people in unfortunate positions, the structure of the ACA is going to make the health system in the US worse instead of better, and like Kristof they believe that struggling Americans deserve better than a suboptimal system.

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