Thursday, May 2, 2013

Bad News for ObamaCare from Oregon

There are basically three basic goals toward which recent efforts at health care reform were aimed.  Two of them are economic: the American health care system costs too much and people need to be protected against the financial burden of health care.  The last is about medicine: people will be healthier if they have better access to health care. 
It is doubtful that ObamaCare can deliver substantial progress toward the first two goals.  It does almost nothing to reduce overall health care spending and it while it will mean that some patients will be relieved of some of the costs of treatment, it is also clear that most of us will pay a lot more. 
What about the last goal?  Does expanding health insurance and in effect cheap or free care improve the health of the recipients?  The state of Oregon recently ran what was, unintentionally, as good a test as one could devise.  They provided funds to add 10,000 new people to Medicaid.  A lottery determined who would get the slots.  Health care experts signed up 6,400 of those who won the lottery and 5,800 of those who entered but didn’t win. 
This provided a large sample.  It met the criteria of a random, controlled test, since the two groups were selected by lot the one provided a control group to compare outcomes with the other.  If access to medical care without financial burden improves health outcomes, this is where you would be able to see it in glowing color. 
Meagan McArdle reports the sad news.  Here is a passage she quotes from the study. 
We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (−9.15 percentage points; 95% confidence interval, −16.70 to −1.60; P=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.
McArdle explains:
No statistically significant treatment effect on any objective measure: not blood pressure.  Not glycated hemoglobin.  Not cholesterol.  There was, on the other hand, a substantial decrease in reported depression.  But this result is kind of weird, because it's not coupled with a statistically significant increase in the use of anti-depressants.  So it's not clear exactly what effect Medicaid is having.  I'm not throwing this out: depression's a big problem, and this seems to be a big effect.  I'm just not sure what to make of it.  Does the mere fact of knowing you have Medicaid make you less depressed?  For that matter, I'm not sure what the policy implication is.  If you wanted a program to cure depression, Medicaid is probably not what you'd design.
The data is in.  Expanding medical insurance did not make an appreciable difference on any objective measure.  The three conditions mentioned above are precisely the ones that we are very good at treating.  One reason for this is that people in the control group usually obtained access to treatment when they sought it. 
I thought from the very beginning of the ObamaCare drama that the real problem was not that Obama was a closet socialist but that neither he nor the Democrats in Congress were bothering to ask any of the most important questions.  They knew what was wrong with the health care system: not enough government control.  They knew exactly what to do about it.  They had known all these things and so didn’t bother to think about them.  They have known them for so long that they cannot remember not knowing them.  It’s not what people think that gets us in trouble.  It’s what they know that just ain’t true. 

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