How to Finance Health Care, Part 2

Four weeks of Health Policy and it's over.  For those who can't understand why anyone would choose a profession being around sick people all the time, I would say that it seems infinitely more depressing to spend a career analyzing our impending economic collapse due to advances in medical technology.  As for what we've learned?  More about that in future posts, but suffice to say it's all about trade offs.  (Pro: it could be beneficial for the patient.  Con: it's expensive.)

How did the course alter our knowledge and opinions?  Seems that our self-proclaimed enlightenment did not persuade us to change our views on financing health care.  (Note: this is a different survey from the last and thus a different sample.)

At the beginning of the course (N=49):

At the end of the course (N=39):

At the beginning of the course (N=49):

At the end of the course (N=39):

Perhaps it's a good thing that we managed to be educated while holding steadfastly to our views.  This sample size of one learned quite a bit from a very unbiased course.

Do Medical Students Know How It Feels to Be Uninsured?

Up in the Ivory tower, do tomorrow's doctors know what it feels like to be without insurance?  About one in three Americans between the ages of 18 and 24 is currently uninsured, and about one in four of those ages 24-64 is.  Harvard requires us to have insurance while we are in school.  Have our classmates ever been without?

N=55 for this survey.

Age (N=53)

The mean age of the respondents was 23.75 years, and the median was 23 years.  About 90% of those who answered were between the ages of 22 and 25.  The oldest student was 33.

Types of Insurance (N=55)

Respondents were not restricted to a single choice, and no time period for a type of coverage was specified.  Thus, coverage types may or may not have overlapped.  All students had had at least one type of insurance: 11 students had had one type, 22 had had two types, 19 had had three types, and 3 had had four types.  Age did not correlate with how many types of insurance a student had had.

All but one student (with private non-group) had been on either dependent or school-based coverage at some point.  All three students on Medicaid had also been on school-based insurance at some point.  One student ("other") had received coverage via an international organization during an internship.

Uninsured at any point? (N=55)

Since Harvard requires that we have health insurance to attend (and Massachusetts has an individual health insurance mandate), the base assumption was that all students are currently insured.  Only one student mentioned in the free-response that s/he was between insurance plans and was planning to get insured soon.

Just over one-third of students had been without insurance.  The average age of this group was 24.5 years, and the median was 24 years.

Regarding the two-thirds of students who had never been without insurance: the average age of this group was 23.35 years, and the median was 23 years.

An F test revealed equal variance between the two groups (p=.00015).  A two-tailed homoscedastic T test revealed a significant difference between the ages of the two groups (p=.039).

Characterization of uninsured period (N=20)

To determine the nature of the uninsured period, I asked two questions: 1) How long total have you been uninsured, and 2) Why were you uninsured?

Answers ranged from one month to 10 years, so a strict average would not be helpful for characterization.  Instead, I will divide time periods into short- (<6 months) and long-term (>1 year) periods.  The reason I chose this classification is that no one was uninsured for a time between 6 months and 1 year, suggesting a natural break in the data.

Short-term uninsured period (N=9)

Three students answered one month; the rest answered "several" or answers between 2 and 6 months.

Six of the nine students described the reason as being in an "in-between" period: either between schools, jobs, or plans.  Two more mentioned simply not buying a plan, and one mentioned being unable to afford private non-group insurance.

Long-term uninsured period (N=11)

All three students who had been on Medicaid were in this group.  Six students mentioned cost, four students mentioned that their parents did not have coverage, and one student mentioned having a part-time job without health coverage.

Revised graph of insured vs. uninsured

No other questions about demographics or attitude were asked.  This is simply a snapshot of 55 first year HMS students.  Slightly over one third of them have been without insurance at some point, and one fifth of them have experienced being uninsured long-term.

Body Donation Preferences After Taking Anatomy: Take 2

Medscape's The Differential is a collection of medical student blogs. Garnering about 1000 views each day, the international audience is (presumably) composed mainly of medical students of all years, with a smattering of residents and higher-ups.

We (the bloggers) are allowed to create a single-question poll with our post.  So, how does national/international medical student/resident opinion on body donation compare with that of Harvard first years' fresh out of anatomy (original post here)?  The results are fairly similar.

Another Quick-and-Dirty Survey: How to Finance Health Care?

Thank goodness the Health Policy course at Harvard is not optional.  Health care coverage is relevant, nonintuitive, and downright confusing.  Economics, policy, and politics are certainly not topics I have learned much about from a source other than the media.  Every day, for four weeks, we learn about geographical variations in health spending, insurance, Medicare and Medicaid, cost growth, managed care, medical malpractice, health care quality, and health care reform.  This is week one.

I am curious about our class's sentiments about how health care should be funded.  I am also interested whether that sentiment will change after we are (presumably) better educated by the end of this month.  (I plan to send out an identical survey at the end of the course.)

The survey simplifies almost to the point of ridiculousness.  Should funding for health care head in a private or public direction?  Of course, there are many, many different and complicated models of coverage: for example, "universal coverage" does not necessarily entail a single payer or even completely public funding.  I intentionally left out the concept of mixed (public and private) funding, since that is what exists today and I suspect most of my classmates would fall into that camp.  I am more interested in the direction that they think health care coverage should go--should we encourage private or public entities to fund it?  Which way do we lean, on a very superficial level?  Does it correlate with self-reported knowledge of policy?  Will it change after this course?

N=49

Correlation between "self-reported knowledge" and leaning?  Size of private funding group (N=7) is too small to draw any conclusions.

Caveat: "Self-reported knowledge" is an incredibly subjective measure.  It could also reflect ego more than knowledge.

The average knowledge score for those who leaned toward private funding was 2.9, and for those who leaned toward public 2.3.  

No one who self-rated a 1 on knowledge leaned private.

40% of those who self-rated a 4 on knowledge leaned private.

More and Less

It started with a simple question my classmate asked me while we were on the shuttle: "After taking anatomy, do you think you're more or less likely to want to donate your body to medical science?"  I paused, sat back.  It was--to borrow a cliché--really complicated.


How much did I know about the fate of a donated body before I stepped into the anatomy lab in scrubs with scalpel in hand?  On one hand, thinking of young aspiring physicians, I could have romanticized the role of a donor.  The invaluable experience of learning from flesh rather than books.  The indelible impact of feeling for organs, finding them, taking them out of their cavities, scrutinizing them, remembering them, and using the knowledge gained to cure others.


However, the past six weeks have been graphic.  Sterile donor consent forms are not sensual experiences.  They do not show the prodding of genitals and orifices with probes.  They do not replicate the sound of sawing the skull in two.  They do not convey the smell of rummaging through the bowels, or the feel of dry, leathery flesh.  Now that we are "informed"--in every sense of the word--would we want the same fate for our own bodies?


Or--now, do we even more acutely realize and appreciate the significance of such a gift?  Would this inspire us to want to give back to future generations of those like us?


Curiosity led me to send out a one-minute, five-question survey to my 200 classmates.  I received 75 responses.  The raw results are below.  In the next post, I will analyze these numbers further and discuss them.

Rather predictably, more students--nearly 50% more--began to think about their own body donation after taking anatomy.  No one who had answered "yes" for the former question answered "no" for the latter.

Before taking anatomy, about one third of students considered themselves "likely" or "very likely" to donate their bodies.  After taking anatomy, this fraction dropped a bit.

The more striking difference was the increase in students unlikely to donate their bodies after taking anatomy.  Fewer than half considered themselves "not likely" or "not at all likely" to donate beforehand.  After the course, that number grew to greater than half.

To note:

No one in any instance who had answered “yes” for the previous questions (they had thought about body donation) left these questions about likelihood blank.

Before anatomy: Since only 44 students claimed they had thought about body donation, I expected to receive this number of responses for the follow-up question.  However, 11 people most likely interpreted the question conditionally ("If you had thought about body donation, how likely would you have been to donate?") and thus answered.  I kept their responses for completeness.

After anatomy: Once again, based on the last question, I expected to receive 65 responses.  Similarly, I am including the extra 5 answers for completeness.

These results are consistent with the findings that taking anatomy caused more students to become less likely to donate their bodies.  Several questions remain.  How often did students experience complete changes-of-heart, such as switching from "likely" to "unlikely"?  Did students with stronger feelings about their likelihood of donating stick with them more steadfastly?  How did the 21 students who had not thought about donating their bodies before anatomy feel after it?

Since I have the individual surveys, I can be transparent and specific.  Next post coming soon.