Health Reform And Race: Too Early For Answers On Death Rates

A tip of the hat to loyal CommonHealth reader Dennis Byron, who — quite rightly — gets irritated when he sees potentially misleading interpretations of statistics. (Check out his new blog on Massachusetts health statistics here.)

On Dec. 15, I headlined a post, "Latest State Death Report Is Out; Is Health Reform Helping Only Whites Live Longer?" At issue were the numbers on "amenable mortality" — deaths "from certain causes that should not occur in the presence of timely and effective medical care." Among the report's highlights was this:

The amenable mortality rate declined 6% since health care reform was implemented. When the amenable mortality rate for 2008 is compared with that of 2006 (before health care reform), the state rate went down from 82.5 (deaths per 100,000 population) to 77.4. This decline was only for Whites. There has been no change in the amenable mortality rate for Blacks, Hispanics, and Asians since 2006.

You can see why I asked the question. But let us never assume that correlation equals causation. Dennis pointed out in a cogent comment that I was likely jumping to a false conclusion, that health care reform had already affected the stats on amenable mortality. He noted, in part:

it's intuitively unlikely that a few hundred thousand people out of 6,500,000 having healthcare insurance in 2007 that they didn't have in 2006 moved the needle much in either direction on 5000 total deaths out of over 6,000,000 people under 75, especially if as you have blogged about elsewhere, they can't get to see a doctor."

I ran Dennis's comments by the state Department of Public Health,

which oversees the death report, and have been delinquent on posting their response. This came from the department spokeswoman, who was quoting the senior demographer/epidemiologist in the bureau of health information:

I think that the blogger is mostly correct in his analysis of amenable mortality and health care reform. Amenable mortality decreased 1.7 percent per year from 2000-2002, and then, declined more steeply at about 4% per year until 2008 (our latest death stats). So, there was a downward trend that began before health care reform, and has continued after it. Since health care reform, we have compared pre- to post- health care reform data pretty routinely, and it is easy to see why readers would believe that we are suggesting that any changes were caused by health care reform. We must be more careful to provide the context for our comparisons. We must also be careful to note that point-in-time comparisons, e.g., comparing the values for the single year 2006 with those of 2008, do not constitute trends. It turns out that, when I looked at the trends in amenable mortality from 2000 to 2008, amenable mortality for all race groups has been declining, though at different rates.

The blogger is also correct to point out that the effects of health care reform on amenable mortality will take many years to see, and depending upon what else is happening in our state (e.g., economic downturn), they will be problematic to analyze. The analysis of health care reform will require a much more in-depth study than our surveillance reports afford.

Dennis sent in his own inquiry, and describes the response on his blog:

The DPH's reply via email:

"We will have to be more careful when we make comparisons that lead to such implications in the future. We will have to include more language like,

'healthcare reform was concurrent with an already declining trend in amenable mortality.'

"Thanks for pointing this out."

And he comments further:

The response is a little weaker than I would like to see given that the pre-Romneycare declining trend covered 6 years and the post-Romneycare concurrency only covered a year and a half. I'd like to see them withdraw the report and rewrite it without the propaganda. Otherwise this misleading information exists forever on the Internet.

Or maybe the DPH could just amend the report to say that the amenable mortality rate declined concurrent with the Red Sox winning a couple of pennants and the Patriots winning a couple of Super Bowls. Maybe the old town teams are the reason for better health — as measured by amenable mortality — all through the past decade in the years before so-called healthcare reform.

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