Sometimes we get so caught up in the
details of health care reform that we forget the real purpose—to
improve people's health.
A new study by Charles Courtemanche and Daniela Zapata, published by the National Bureau of Economic
Research, examines the health effects of Massachusetts' 2006 health
care reform bill, commonly called “Romneycare.” This effects of
this reform are important because it is nearly the same as the
Affordable Care Act (ACA).
It may sound silly to ask whether
expanding people's access to medical care improves their health, but
the outcome of the study was not obvious. Critics of health care
reform sometimes claim that people will not take advantage or make
good use of medical care and their health will be unchanged. More
importantly, the
moral hazard
hypothesis claims that when health care is available at low cost,
people will take unnecessary health risks, such as smoking and
overeating. The result could be a decline in their overall health,
accompanied by an increase in medical spending.
Previous studies
have generally found improvements in health following increased
access to care. The most impressive is
the Oregon Health Study,
which found a 13% increase in the number of people reporting
themselves to be in good or excellent health following enrollment in
Medicaid.
The data for this
study come from a survey conducted by state health departments and
the Center for Disease Control between 2001 and 2010. It includes
answers from 2.8 million respondents from all 50 states and the
District of Columbia. The study is a time series design. Health
care reform in Massachusetts went into effect in March 2006, but the
implementation was gradual and was not completed until July 2007.
The research question is whether there were any changes in the health
of Massachusetts residents around those times that did not occur in
other states. The analysis controls for irrelevant variables such as
age, income and marital status.
The main dependent
measure was a self-report health question asking respondents to
classify their overall health as either poor, fair, good, very good,
or excellent. The results showed an improvement in health while the
reform was being implemented (from April 2006 to July 2007), and
approximately twice as large an improvement after it was fully
implemented. These changes did not occur in other states at the same
time. To put this into perspective, it is estimated that 1.4% of the
population went from being in either poor, fair or good health to
either very good or excellent health. Considering the overall cost
of the program, Massachusetts spent $9,782 per year for every
individual whose health improved from poor, fair or good to very good
or excellent. Of course, having more people in very good or
excellent health might save money in the long run.
This analysis
includes everyone. However, if you look specifically at those people
who acquired health insurance as a result of the reform, their
probabilities of being in poor, fair or good health went down by
6.2%, 9.8% and 8.5% respectively, while their probability of being in
very good health and excellent health went up 8.5% and 16%. This is
comparable to the results of the Oregon study.
The
main concern about this measure is that self-report questions are
subjective and can be influenced by various biases. For example,
people might have expected their health to improve due to the reform.
On the other hand, access to medical care might make people more
aware of the health problems they have. Therefore, the survey
included several other measures. People were asked the number of
days out of the past 30 that they were not in good physical health,
that they were not in good mental health, and that they experienced
health-related functional limitations. They were also asked the
number of minutes per week they spent in moderate and vigorous
physical activity, whether they experienced joint pain, and whether
they smoked. Finally, their body mass index (weight/height2),
or BMI, was calculated. Since these questions are more specific,
they should be less subject to bias.
The
results showed significant improvements on all of these measures with
the exception of vigorous exercise and smoking. The fact that
smoking did not increase and that BMI was reduced casts doubt on the
moral hazard hypothesis that people would take more health risks. In
fact, the overall pattern suggests that people were heeding medical
advice.
Finally, internal
analyses showed that, while almost every subgroup showed improvements
in health, women improved more than men, and people between 55 and 64
(the oldest group not eligible for Medicare) showed the greatest
improvement. Those in the lowest income category, who were eligible
for a state subsidy to help purchase their insurance, showed greater
improvement, and blacks improved more than other races. The authors
estimate that health care reform reduced black-white health
inequality by 21.5%.
Does this study
predict a positive effect of the ACA on health if it is implemented?
Maybe. But the ACA includes cost-cutting measures that were not part
of the Massachusetts plan, such as reductions in Medicare spending,
which might reduce the gains that would otherwise be expected. On
the other hand, Massachusetts had one of the lowest percentages of
uninsured citizens of any state, so implementing these same reforms
nationwide might result in a greater improvement in the health of the
nation.
I presume these
successful results will be embarrassing to Governor Romney,
who has repudiated his own health care reform in search of the
approval of the bewildered herd of Elephants.
