Re: the marginal ineffectiveness of medicine

Robin Hanson (
Sat, 26 Jun 1999 10:04:02 -0700

Damien B. write:
>the response from an Aussie medico. ...
>>... my claim that medicine has a low marginal value.
>>The clearest evidence we have on this is the RAND Health Insurance
>>Experiment [Newhouse et al, "Free for All?" '93] ...
>that the comparisons are between groups who have different levels of
>insurance. ... you wouldn't expect much difference in health
>outcomes because they are, for all intents and purposes, indistinguishable.
>No-one is going to miss out on life-saving surgery. ...
>The paper doesn't test the "effectiveness of medicine",
>because it's not comparing a group who receive medical care with a group
>who don't receive medical care (an experiment that I doubt will ever be
>performed). The paper doesn't actually test the "marginal effectiveness of
>medicine" so much as it tests the cost-benefits of different insurance
>options. And, not surprisingly, it found that most health indicators are
>the comparable, but people who don't pay for their health care use more
>services for very little benefit.

"Ethical" reasons supposedly don't let us experimentally test the difference between normal vs. no medicine. So this is the best we have. When you
make people pay for their medicine, they choose to take 25% less of it, which makes almost no health difference. That foregone medicine is what I mean by "marginal".

The experiment showed that this foregone medicine is, by standard medical measures of "appropriateness", just as appropriate as the other non-marginal medicine. If people are very good at knowing when a medical problem is serious
enough that they aught to seek medical attention, the non-marginal medicine might be much more valuable (even if it is just as "appropriate"). If, however, people are very bad at knowing when a health problem is serious, non-marginal medicine must be about as useless as marginal medicine.

>... it's not true that there were "no significant"
>differences between the groups. At least one paper I found on Medline tried
>to explain why eyesight was reportedly significantly improved in the
>high-insurance group.

I did mention better eyesight and filled teeth in my summary.

>The other paper mentioned must be a dud reference. The Lantz paper I picked
>up in that issue of JAMA doesn't actually deal with the topic Hanson uses
>it for. The paper tried to answer whether altering the health-risk
>behaviour of lower socioeconomic groups would lead to a significant
>improvement in health outcomes. ...

That is the right paper. What the authors intended it for is irrelevant to my point. I just wanted to point out there there are a number of other factors which seem to have a roughly two orders of magnitude larger influence on health than that found by medicine in the RAND study. Yes, that wasn't a controlled experiment, but we don't have controlled experiments
for the big important factors, unfortunately ("ethics" again).