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. 

The Virtuous, the Beautiful, & Margaret Thatcher.

That was one of Margaret Thatcher’s finest hours.  She had more than one.  I fell head over heels in love with her back then.  The passion has not faded with time.  If there are sons of Hercules, so also there are daughters.  As I have written in several Facebook posts, I would gladly have had her children. In honor of her passing, I offer this post. 

I have been enjoying an extended conversation about virtue with intrepid reader and friend, Miranda.  You can read it here.  One challenge that she posed goes like this:

Dr. Blanchard: Congratulations on your presentation and thank you, once again, for taking the time to respond to my questions. I have been trying to figure out why your description of virtue troubles me so much. It is not, I think, so much because I think you are using circular logic as it is that I am not sure your definition is particularly useful.

If someone was interested in becoming a virtuoso and they asked you what a virtuoso was, you might tell them a virtuoso was someone who played brilliantly. But what is brilliance? How does one go about playing brilliantly?

I suppose you could say that he might imitate another virtuoso, just as you might tell someone who was interested in being virtuous to imitate a virtuous man – but without having a more defined idea of what actually makes someone a virtuoso or a virtuous man, how would you really know that the person you copied was a virtuoso or a virtuous man?

…Some people have many virtues, along with many vices. Most people are a mix or virtue and vice. How do we know what criteria to use to determine whether or not we are actually following the example of a virtuous man? Is it all subjective?

If I understand the objection here, it goes like this: if virtue is what virtuous persons do and virtuous persons are persons who do virtuous things, then recognizing either the one or the other presupposes that we know what virtuous actions and virtuous persons are.  How do we gain that knowledge in the first place?  

I argue Platonically that virtue is an idea, or form, or realm in design space that we come to recognize in the same way as we recognize mathematical ideas.  If moral virtue is not as precise as mathematics, neither is there as much disagreement about it as is often supposed.  Even the vicious recognize what virtue is, for how else could they pretend to be virtuous? 

However, let me employ one more analogy.  What is health?  We come to know what it is when we recognize it in ourselves and in other people.  Plato’s Socrates distinguished between medicine, which restores health, and gymnastics which hones it to perfection.  If you asked for a precise definition of a healthy person and a healthy diet, regimen, etc., one that would tell you in advance which actions and persons are healthy, you are in for a disappointment.  The same food may be very healthy for one person and very unhealthy for another who is allergic to it.  An exercise that is very good for a healthy athlete may be injurious to someone with a torn muscle.  There are very vigorous debates about what things promote health and what things inhibit it.  That does not mean that health is at all subjective. 

I think that much the same is true of the virtues.  We come to know them the same way that we come to know what is healthy.  As evidence of this, I submit the example of Margaret Thatcher. 

I once had a photo of Thatcher walking with Ronald Reagan, Helmut Kohl, and Francois Mitterrand.  These were the four that stood up to the Soviet Union during the most critical moment in the Cold War.  The Soviets had deployed short range nuclear missiles in Eastern Europe in the hopes of decoupling Western Europe from the United States.  Reagan moved to place similar weapons in NATO territory.  The left in Europe and the U.S. went to war (figuratively) to stop the deployment.  Of course there was no similar movement in the totalitarian bloc. 

Thatcher, Reagan, Kohl, and Mitterrand stood firm.  The direct result of that was the Intermediate Nuclear Forces Treaty, which was unique in so far as weapons were not only withdrawn but dismantled.  The indirect result was the collapse of the Soviet Union. 

I don’t know Kohl or Mitterrand well enough to judge but I submit that Reagan and Thatcher exemplified the virtues of prudence and courage, at the very least.  They judged correctly how to defeat the enemy without resorting to actual bloodshed.  They held the course in spite of enormous pressures.  If you want to know what virtue is, that would be it.