The naive comparison of mortality between insured and uninsured people decomposes into two terms:
\underbrace{E[Y_i \mid D_i = 1] - E[Y_i \mid D_i = 0]}_{\text{observed difference}} = \underbrace{E[Y_i(1) - Y_i(0) \mid D_i = 1]}_{\text{effect on the treated}} + \underbrace{E[Y_i(0) \mid D_i = 1] - E[Y_i(0) \mid D_i = 0]}_{\text{selection bias}}
Selection bias is the difference the two groups would have had even without insurance.
- People who expect high medical costs are more likely to buy insurance (adverse selection): selection bias pushes towards insurance looking harmful
- People with higher income and education are more likely to be insured and are healthier anyway: selection bias pushes towards insurance looking helpful
Without a design, we cannot know which force dominates, or by how much.