Problems with an Indiana Survey on Health Care Myths.--

A SURVEY OF HEALTH REFORM MYTHS

I have seen several references to a University of Indiana opinion study on the public’s belief in health care myths. Because the study was conducted by reputable professionals, I had assumed that the study’s sponsors would know more about the theory of opinion polling than they do.

Dr. Aaron Carroll, who directs the IU Center for Health Policy and Professionalism Research, commented about his center’s study on MSNBC:

“More than half of Americans believe so many of these myths that it’s really quite clear that the administration and Congress just aren’t getting the message out about what health care reform is really going to do.”

If you look at the survey, you see that most of the supposed knowledge questions do not turn completely on known facts, which can have true or false answers. The myth questions are mostly subjective — expectations or predictions about the future — which by nature have no right or wrong answers. This distinction is axiomatic in the field of survey research.

Of course, most of these predictions could at some future time be determined to be true or false by most fair-minded observers, but not now. A few of the predictions about the future strike me as being extremely likely to turn out to be correct (if Obama's plans were enacted) and a few strike me as strike me as being extremely likely to turn out to be incorrect predictions. If Obama's plans are ever enacted, time will tell. But they are not now “myths.”

EXPECTATIONS OF FUTURE EVENTS IN SURVEY RESEARCH

Expectations of future events are classically understood as subjective questions. Willem E. Saris and Irmtraud Gallhofer distinguish subjective from objective survey variables:

Subjective variables include cognitions, evaluations, evaluative beliefs, feelings, preferences, values, rights, norms and policies, action tendencies, expectations. Objective variables include behavior, past events, demographic characteristics, knowledge, information about time, place, procedures and frequency. . . .

By subjective variables, as stated, we understand variables for which the information can only be obtained from a respondent because the information exists in his/her mind alone. Operationalization of Social Science Concepts by Intuition, Quality & Quantity 38: 235–258, 238, 241 (2004).

Saris and Gallhofer go on to explain Expectations of future events (at p. 246):

Expectations of future events (Graesser et al., 1996) are anticipations of events in which oneself is not involved. . . . For example:

I expect better weather in the near future

. . . The difference with the previous type of assertion [action tendencies] is that an expectation does not relate to the respondent’s own action but it refers to some kind of event which is not connected with one’s own behavior.

Here ends our overview of concepts by intuition that fall under the heading of subjective variables. They are all characterized by assertions based on information that can only be obtained from respondents because they represent subjective variables and these views can not be checked in any way because they are personal views.

In other words, most of the myth questions in the Indiana survey are questions about subjective views (expectations, opinions, attitudes, and beliefs), not currently knowable facts. For a social scientist reporting a survey to call them “myths” violates general principles of opinion polling.

OBAMA’S PROMISE TO MAKE COMPANIES CHANGE INSURANCE PLANS

Before getting into the survey questions themselves, people should remember what President Obama said in his first August town hall meeting on health care in New Hampshire:

Under the reform we're proposing, insurance companies will be prohibited from denying coverage because of a person's medical history. Period. . . .

Now, when we pass health insurance reform, insurance companies will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. And we will place a limit on how much you can be charged for out-of-pocket expenses, because no one in America should go broke because they get sick. (Applause.)

And finally — this is important — we will require insurance companies to cover routine checkups and preventive care, like mammograms and colonoscopies — (applause) — because there's no reason we shouldn't be catching diseases like breast cancer and prostate cancer on the front end. . . .

So this is what reform is about.

I quote this to remind skeptics that President Obama is promising to prohibit insurance companies from offering lower cost plans with high deductibles, which some younger people in good health currently prefer. In other words, some of you who like your current health plans will not be allowed to keep them.

Next: Answering the Questions in the Indiana Health Care Myth Survey.

Answering the Questions in the Indiana Health Care Myth Survey.--

Indiana University’s Center for Health Policy and Professionalism Research (CHPPR) and the Center for Bioethics (IUCB) conducted a study on health care reform myths. In an earlier post I pointed out that the survey researchers were not sensitive to the difference between a knowledge question and a subjective prediction of future events.

Here are the relevant myth questions on the survey and my own comments about what is likely to occur if President Obama's reforms were to be enacted:

Recently, there has been a lot in the news about the health insurance reforms being proposed by President Barack Obama. I am going to read a list of statements about his proposed health insurance reform plan. After each statement, please tell me whether or not you believe it is true. [I have changed the question order.]

1. Millions of Americans will lose their current health insurance.

COMMENT: This strikes me as extraordinarily likely to occur, especially given Obama’s promises quoted in the last post. Given that Obama is proposing to change coverage, plans, and incentives, enough will change that it is either naïve or dishonest (or both) for a survey researcher to call this statement a “myth.”

2. Wait times for health care services like surgery will increase.

COMMENT: This strikes me as extraordinarily likely to occur. Increasing the scope of coverage without appreciably increasing the number of doctors should lead to longer wait times. Again, it is either naïve or dishonest (or both) to call this a “myth.” Further, the Massachusetts experience is not encouraging.

3. Health care services such as treatments, physicians, and care will be rationed.

COMMENT: Given that the White House admits that rationing is already happening by private insurance carriers, I don’t understand why they think that rationing in some form is unlikely under their proposed reforms. I suspect, however, that the government will find it difficult to make many of the tough decisions, so that most "rationing" will occur not by the government denying care but by doctors being unable or unwilling to treat many of the patients covered under government or private insurance plans. Time will tell.

4. Reforms will cover more Americans by making cuts to Medicare.

COMMENT: Given President Obama’s own statements, I don’t see how any honest researcher can call this a “myth.” In his New Hampshire town hall, Obama said that he will accomplish health care reform “without adding to our deficit over the next decade, largely by cutting out the waste and insurance company giveaways in Medicare that aren't making any of our seniors healthier.” So Obama is promising to make large cuts in Medicare funding without compromising the health of seniors. I have my doubts whether Medicare funding will be cut substantially by anything other than longer waits for Medicare patients who want treatment under Obama's health care reform. Time will tell.

5. Tort reform, which would limit the amount of money awarded to injured patients in malpractice cases, will decrease health care costs.

COMMENT: Given the conflicting scholarly literature on this, I don’t see how any honest researcher could call this a “myth.” For example, Ronen Avraham and Max Schanzenbach reviewed 7 tort reforms and concluded that some had no effect while others “are effective in reducing healthcare costs. The magnitude of the effects on price sensitive groups suggests that some tort reforms can reduce health care costs by as much as two percent.”

6. Small businesses will be hurt.

COMMENT: Time will tell, but I would expect this prediction to be more likely to be TRUE than not.

7. The Federal Government will become directly involved in making personal health care decisions for you.

COMMENT: Whether this is likely to turn out to be TRUE depends on what is meant by “directly involved in making personal health care decisions for you.” By creating panels that will mandate some coverage and refuse to reimburse other coverage, this assertion will probably be TRUE for many people. But if the question means that government officials will decide on your treatment on a case-by-case basis, this is likely to be FALSE. Participants in the public option, however, may have case-by-case decisions made on which sorts of coverage will be reimbursed, given their diagnosis and condition.

8. The Federal Government will make decisions about whether you will be treated or not.

COMMENT: Again, whether this is likely to turn out to be TRUE depends on what is meant by making “decisions about whether you will be treated or not.” By creating panels that will mandate some coverage and refuse to reimburse other coverage, this assertion will probably be TRUE for many people. But if the statement means that government officials will decide on your treatment on a case-by-case basis, this is likely to be FALSE. Participants in the public option, however, may have case-by-case decisions made on which sorts of coverage will be reimbursed.

9. A government official will be put in charge of your medical records.

COMMENT: It seems likely that a “government official will be put in charge of” making sure that your medical records are collected and shared and in evaluating your records along with almost everyone else’s. If this is what the statement means, then it will probably turn out to be TRUE. If the statement instead means that the primary keeper of your records will be the government, I would guess that this will turn out to be FALSE.

10. Private insurance coverage will be eliminated.

COMMENT: If this means ALL private insurance coverage will be eliminated, this should turn out to be FALSE in the short and medium term. In the long run, time will tell.

11. Employer-sponsored insurance coverage will be eliminated.

COMMENT: If this means that ALL employer-sponsored insurance coverage will be eliminated, this should turn out to be FALSE in the short and medium term. In the long run, time will tell.

12. A public insurance option will put private insurance companies out of business.

COMMENT: If this means that ALL private health insurance companies will go out of business, this should be turn out to be FALSE in the short and medium term. In the long run, time will tell.

13. The government will require the elderly to make decisions about how and when they will die.

COMMENT: This should be turn out to be FALSE in the short and medium term. The existing law already requires that people admitted as inpatients to hospitals must be asked whether they want an advanced directive. In the next decade, I think it unlikely that the elderly will be REQUIRED to fill out advanced directives. Certainly, none of the bills I've seen would require this.

14. The elderly will have to undergo euthanasia counseling every 5 years.

COMMENT: This should turn out to be FALSE. Certainly, none of the bills I've seen would require this.

15. Taxpayers will be required to pay for abortions.

COMMENT: Time will tell. It is likely that abortion will be covered in a public plan, so whether “Taxpayers will be required to pay for abortions” turns on whether the participants in a public plan will actually bear ALL the government’s cost of such a plan. If they do, then this will turn out to be FALSE. If instead the public option is subsidized by taxpayers (as seems probable whatever Obama's hopes might be), then this statement will likely turn out to be TRUE.

16. All illegal immigrants will be covered.

COMMENT: Given the extreme wording of the statement, as unrealistically stated this assertion will almost certainly turn out to be FALSE. But this is a ridiculous question because not even all US citizens will be covered by insurance plans; some will pay penalties for noncoverage. If the statement were reworded to say that “some illegal immigrants will be covered,” then this expectation might turn out to be TRUE, if only because enforcement is likely to be lax. Time will tell.

17. A “public option” that competes with private insurance will be too expensive for the United States to afford.

COMMENT: Time will tell.

18. A “public option” will increase health care costs, not lower them.

COMMENT: Time will tell.

19. A “public option” will actually increase premiums for Americans with private insurance.

COMMENT: Time will tell.