title: Attrition in the RAND Health Insurance Experiment: a response to Nyman.
abstract: In a prior article in this journal, John Nyman argues that the effect on health care use and spending found in the RAND Health Insurance Experiment is an artifact of greater voluntary attrition in the cost-sharing plans relative to the free care plan. Specifically, he speculates that those in the cost-sharing plans, when faced with a hospitalization, withdrew. His argument is implausible because (1) families facing a hospitalization would be worse off financially by withdrawing; (2) a large number of observational studies find a similar effect of cost sharing on use; (3) those who left did not differ in their utilization prior to leaving; (4) if there had been no attrition and cost sharing did not reduce hospitalization rates, each adult in each family that withdrew would have had to have been hospitalized once each year for the duration of time they would otherwise have been in the experiment, an implausibly high rate; (5) there are benign explanations for the higher attrition in the cost-sharing plans. Finally, we obtained follow-up health-status data on the great majority of those who left prematurely. We found the health-status findings were insensitive to the inclusion of the attrition cases.
authors.affiliation: Harvard University, Boston, MA, USA.
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Newhouse
authors.forename: Robert H
authors.initials: RH
authors.lastname: Brook
authors.forename: Naihua
authors.initials: N
authors.lastname: Duan
authors.forename: Emmett B
authors.initials: EB
authors.lastname: Keeler
authors.forename: Arleen
authors.initials: A
authors.lastname: Leibowitz
authors.forename: Willard G
authors.initials: WG
authors.lastname: Manning
authors.forename: M Susan
authors.initials: MS
authors.lastname: Marquis
authors.forename: Carl N
authors.initials: CN
authors.lastname: Morris
authors.forename: Charles E
authors.initials: CE
authors.lastname: Phelps
authors.forename: John E
authors.initials: JE
authors.lastname: Rolph
mesh_terms: D017047:Cost Sharing / Q000941:ethics*; D017048:Health Care Costs; D006291:Health Policy; D006297:Health Services Accessibility / Q000191:economics / Q000941:ethics*; D006304:Health Status; D006801:Humans; D019458:Insurance Coverage / Q000191:economics / Q000458:organization & administration*; D007348:Insurance, Health / Q000191:economics*; D017057:Medically Uninsured; D028681:Moral Obligations; D012946:Social Welfare / Q000191:economics / Q000941:ethics*