Does Free Care Improve Adults' Health?: Results from a Randomized Controlled Trial

Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost? In an effort to answer this question, we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been randomly assigned to a set of insurance plans for three or five years. One plan provided free care; the others required enrollees to pay a share of their medical bills. As previously reported, patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often. For persons with poor vision and for low-income persons with high blood pressure, free care brought an improvement (vision better by 0.2 Snellen lines, diastolic blood pressure lower by 3 mm Hg); better control of blood pressure reduced the calculated risk of early death among those at high risk. For the average participant, as well as for subgroups differing in income and initial health status, no significant effects were detected on eight other measures of health status and health habits. Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence, favorable or adverse, of free care for the average participant. For some measures of health in subgroups of the population, however, the broader confidence intervals make this conclusion less certain. (N Engl J Med 1983; 309:1426–34.) SPENDING at least some money on medical care is indisputably worthwhile. But does spending yet more buy still better health? In individual cases, the answer may be an obvious yes or no, but in the population as a whole the point of diminishing (or absent) returns has been difficult to identify. 1 2 3 4 5 6 7 Critics of the existing system have contended that developed countries spend too much on medicine; they argue that this practice increases iatrogenous illness. 8 , 9 The extreme versions of this argument, constituting a kind of "therapeutic nihilism," have been cogently criticized, 10 , 11 and in this country public policy has proceeded for more . . .