Showing posts with label Affordable Care Act. Show all posts
Showing posts with label Affordable Care Act. Show all posts

Saturday, May 10, 2014

Health Insurance and Mortality, Part 2

Please read Part 1 of this post before continuing.

Not surprisingly, there have been several criticisms of the Sommers, Long and Baicker study. Here are the main ones I've been able to identify so far, and my comments on each.
  • The results contradict those of the Oregon Medicaid study. A 2013 study by Baicker, et al., examined the effects of Medicaid expansion in Oregon using a randomized control group design. (The opportunity to sign up for Medicaid was determined by lottery.) Although this study found economic and psychological benefits of Medicaid, its effects on objective measures of health were disappointing.  Blood pressure, cholesterol and blood sugar levels were all lower in the Medicaid group, but the differences were not statistically significant. However, the Oregon study's sample size was too small to detect medically important health benefits. The Massachusetts study has many more particpants. If the same percentage decline in mortality observed in the Massachusetts study had been seen in Oregon, it too would not have been statistically significant. The two studies are not inconsistent. An important strength of the Massachusetts study is its larger sample size. Furthermore, it measured the effects of the entire health reform package, not just Medicaid expansion.
  • It costs too much. Using the Sommers, et al., data, Cannon calculated that it cost Massachusetts $4 million per life saved. He argues that this is not cost effective. However, this assumes that the only benefit people received from Romneycare was when it saved their lives. It ignores the many health and quality of life benefits people receive from medical treatments for non-life-threatening illnesses and injuries. What is the value of a knee or hip replacement that allows a person to walk free of pain for 20 years? How do you measure the benefits to a family of avoiding bankruptcy and the loss of their home?
  • Massachusetts is different from other states. Massachusetts is “whiter and more affluent” than most other states, but the matched comparison groups control for race and income. It could be argued that Massachusetts has a more effective health care system (more doctors, better-equipped hospitals) than other states. However, a convincing alternative explanation must explain not just lower mortality in Massachusetts, but all the results. Why did the mortality rate change from 2001-2005 to 2007-2010? Wouldn't a better health care system be expected to help people over 65 as well? As Sommers, et al., state in their conclusion:
Although we cannot rule out unmeasured confounders, it is challenging to identify factors other than health care reform that might have produced this pattern of results: a declining mortality rate in Massachusetts since 2007 not present in similar counties elsewhere in the country, primarily for health care-amenable causes of death in adults aged 20 to 64 years (but not elderly adults), concentrated among poor and uninsured areas and not explained by changes in poverty or unemployment rates.

Of course, health insurance is useless if there are no doctors or hospitals in your area. The quality of the health system may have interacted with health care reform to produce a better result in Massachusetts than would be expected in other states. This does not explain away the results, but it may limit our ability to generalize from them.
  • More research is needed. This cliché is, of course, trivially true. However, it is unrealistic to expect definitive studies of effects of the Affordable Care Act (ACA), since it is being implemented simultaneously in all 50 states. There are no experimental and control groups, only before and after comparisons, the results of which can easily be dismissed as caused by other changes taking place in society at the same time. About the best we can expect will be comparisons between states that do or do not expand Medicaid. (Pennsylvanians will be happy to know that, thanks to Governor Tom Corbett and our legislature, future researchers will be counting the number of excess deaths in our state.) However, states that are not expanding Medicaid are already known to differ both economically and politically from other states. And while Medicaid expansion is an important provision of the ACA, it is only a part of it.

In short, the Sommers, et al., study may be the best that is available for the foreseeable future. Even conservative critics of health care reform are granting it grudging respect.  Megan McArdle stated, "(A)fter yesterday's report, I've revised the probability of 'huge benefits' [from health care reform] upward, and you should do the same."

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Thursday, May 8, 2014

Health Insurance and Mortality, Part 1

In 2006, Massachusetts implemented the country's first comprehensive health care reform (“Romneycare”). It made health insurance mandatory for nearly all citizens, expanded Medicaid to cover people earning up to 150% of the federal poverty level (FPL), and provided health insurance subsidies for people with incomes up to 300% of FPL. It became the structural model for the Affordable Care Act (ACA). A previous study showed that Massachusetts residents reported themselves to be in better health following the implementation of Romneycare. A new study out this week shows that health care reform significantly reduced the mortality rate in Massachusetts compared to nearby states. This is the bottom line in health care research. It's good news not only for the ACA, but for single payer advocates as well, since single payer would further expand the number of people covered by health insurance and would presumably reduce the red tape and out-of-pocket costs that keep some people from using health care.

The study, by Drs. Ben Sommers, Sharon Long, and Katherine Baicker, is a quasi-experimental design. It lacks an important feature of true experiments—random assignmnent of participants to conditions—but attempts to compensate for this by using a matched comparison group that controls for most plausible alternative explanations. In this case, the experimental group was the citizens of Massachusetts. Each county in Massachusetts was matched with a comparison county drawn from a nearby state. The counties were matched for age distribution, race and ethnicity, poverty, income, unemployment, lack of health insurance, and their existing mortality rate. The authors compared the mortality rates of adults under 65 from 2001-2005 (prereform) to 2007-2010 (postreform). Here are the results.
  • Mortality in Massachusetts declined 2.9% relative to the comparison group. This is equivalent to 8.2 deaths per 100,000 people, or one death prevented for every 830 people who obtain health insurance. The New York Times calculates that a national 2.9% decline in mortality among adults under 65 would translate to about 17,000 lives saved per year. Harold Pollack claims that the number is as high as 24,000 per year.
  • Mortality “amenable to health care,” i.e., from causes such as cancer, heart disease and diabetes, declined 4.5% relative to the control group. Mortality from causes not amenable to health care was unchanged. See the chart below.


  • Mortality among people over 65 was unaffected. This is to be expected, since senior citizens already had Medicare.
  • Reductions in the mortality rate were greatest among counties with the lowest incomes and the lowest rates of insurance coverage prior to reform.
  • As you would expect, the study also found significant increases in insurance coverage, access to medical care, and self-reported health in Massachusetts compared to the comparison group.
As health care expert Austin Frakt has noted, this study constitutes the strongest evidence yet that having health insurance can save your life. Nevertheless, the study is not without its critics. I will look at some of those criticisms in Part 2 of this post.

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Tuesday, May 6, 2014

Bankruptcy Rates as an Indication of the Rate of Underinsured


In my post on the Gallup polls on improvements in the uninsured rates.  I speculated that looking at the rates of medical bankruptcies would provide an indication of the number of underinsured in the US as the Affordable Care Act (ACA).  Data on the number of bankruptcies is available from American Bankruptcy Institute which distinguishes between the number of business and individual bankruptcies each year by state.  The reasons for individual bankruptcies is not given.  Research by PNHP has been done prior to the passage of the Affordable Care Act showing that medical bankruptcies account for 62.1% of all personal bankruptcies.  I have not found recent data on medical bankruptcies (filers or court records would have to be surveyed which is difficult to do) but I can look at overall individual bankruptcy rates in recent years.

 The raw number of filings for each state can be seen here for the years 2007-2009.  The numbers were adjusted for state's estimated population for each year to allow for proper comparisons.   The rates are presented as bankruptcies per 1,000 persons.  The US rate increased from 2.70 in 2007 to 4.38 in 2011 which is a 62.15% increase.  The US rate did decrease from 2010 (4.91) to 2011 (4.38) as well as every state except Delaware.  The US rate is shown in the solid blue line above.

 California and Arizona had the highest increases from 2007-2011 as can be seen in the table below.  Their increases were both by more than 220% (more than three fold) which is still staggering even after adjusting for their populations.  California is presented in the graph above in the solid black line. 

Of particular interest to health care advocates is Massachusetts (with the dotted purple line above) which has had a version of the ACA since 2006.  The bankruptcy rate there has increased by 43.05% which is below the national rate of 62.15%.  However, if the 50 states plus DC and Puerto Rico are ranked from highest to lowest it ranks exactly in the middle in the change in rate.

 Our state, Pennsylvania, had one of the smallest increases at 10.24% (2.30 to 2.54) with a decrease from 2.98 to 2.54 from 2010 to 2011.  Vermont (the dotted yellow line), which passed a single payer plan to be implemented in 2017, had a 31.19% increase in its rate but still ranked 49th out of 52 states in it's 2011 rate.  Only Alaska, DC, and South Carolina had lower rates in 2011 than Vermont.  The state with the lowest rate of change is North Dakota at 1.69% (from 1.76 to 1.79) and is represented with the solid green line.

 All of this begs the question how much of the increase in the rates are due to changes in health care or other factors.  There is no clear answer for that right now though the Massachusetts plan has not halted the rise in the overall rate in personal bankruptcies.  I will analyze this data for correlations with other rates such as the uninsured, health outcomes, and income to see if there is an association with these variables.



STATE
Population Adjusted Non Business Bankruptcy Rates by Year (per 1000 persons)
% change 2007-2011
2007
2008
2009
2010
2011
US (50 states + DC and PR)
2.70
3.49
4.55
4.91
4.38
62.15%
AK
0.92
1.18
1.28
1.46
1.30
41.27%
AL
5.04
6.15
7.18
6.98
6.20
22.92%
AR
4.02
4.69
5.51
5.46
4.83
20.02%
AZ
1.69
2.94
5.21
6.42
5.43
220.81%
CA
1.91
3.46
5.43
6.73
6.17
223.68%
CO
3.09
4.13
5.41
6.22
5.72
84.85%
CT
1.60
2.21
2.77
3.09
2.57
60.93%
DC
1.18
1.42
1.80
1.97
1.48
25.67%
DE
1.95
2.58
3.32
3.67
3.94
102.51%
FL
2.15
3.44
4.94
5.74
4.76
121.93%
GA
5.20
6.24
7.50
7.91
7.30
40.26%
HI
1.01
1.50
2.24
2.80
2.32
129.32%
IA
2.26
2.58
3.23
3.10
2.48
9.70%
ID
2.47
3.31
4.71
5.09
4.64
87.80%
IL
3.18
4.28
5.61
6.27
5.52
73.49%
IN
4.78
5.99
7.32
7.15
5.92
23.86%
KS
2.82
3.08
3.74
3.81
3.40
20.74%
KY
3.96
4.88
5.70
5.60
4.97
25.57%
LA
3.15
3.37
3.99
4.05
3.70
17.58%
MA
2.08
2.49
3.11
3.51
2.97
43.05%
MD
2.36
3.06
4.42
4.99
4.29
81.64%
ME
1.62
2.14
2.73
2.99
2.55
57.48%
MI
4.50
5.39
6.79
6.75
5.70
26.70%
MN
2.19
3.00
3.90
4.04
3.50
59.99%
MO
3.55
4.17
5.11
5.42
7.84
121.19%
MS
3.74
4.07
4.81
4.67
4.47
19.55%
MT
1.89
1.93
2.66
2.97
2.48
31.40%
NC
2.10
2.34
2.79
2.64
2.32
10.60%
ND
1.76
1.99
2.30
2.35
1.79
1.69%
NE
2.89
3.59
3.99
4.17
3.46
19.73%
NH
2.02
2.69
3.56
3.82
3.38
67.24%
NJ
2.20
2.96
3.96
4.54
4.17
89.40%
NM
1.64
2.17
2.86
3.05
2.63
60.35%
NV
4.09
6.86
10.74
10.78
8.64
111.38%
NY
2.05
2.36
2.80
2.77
2.41
17.87%
OH
4.29
4.93
5.96
5.97
4.97
15.78%
OK
2.41
2.93
3.66
3.84
3.35
38.89%
OR
2.45
3.28
4.67
5.12
4.42
80.58%
PA
2.30
2.53
2.80
2.98
2.54
10.24%
PR
1.99
2.32
2.93
3.24
2.96
49.04%
RI
2.56
3.94
4.68
5.06
4.55
77.52%
SC
1.61
1.82
2.04
1.93
1.65
2.55%
SD
1.61
1.73
2.18
2.37
2.16
33.85%
TN
6.32
7.47
8.43
7.73
7.18
13.47%
TX
1.70
1.69
2.05
2.14
1.89
11.16%
UT
2.42
3.39
5.20
6.41
6.32
161.58%
VA
2.44
3.52
4.46
4.51
4.04
65.77%
VT
1.33
1.96
2.40
2.53
1.75
31.19%
WA
2.34
3.22
4.56
4.88
4.52
93.54%
WI
3.06
3.69
4.76
5.18
4.64
51.73%
WV
2.37
2.79
3.50
3.18
2.48
4.61%
WY
1.42
1.44
2.27
2.64
2.33
63.97%

**Update**

The journal Annals of Internal Medicine compared mortality rates in Massachusetts to those in similar surrounding counties for four years before and prior to plan implementation in 2006.  They found a 2.95% decrease in the mortality rate compared to the surrounding counties from 2007 to 2010.  Over the same period Massachusetts had a 68.75% increase in the rate of bankruptcies.  

I could not access the journal article so I do not know what the control counties were.  However Rhode Island and Connecticut are similar states in demographics.  Rhode Island had a 97.65% increase and Connecticut had a 93.13% increase in the personal bankruptcy rate.  Is the lower increase in Massachusetts bankruptcies due to their health care law?  I cannot say.  The national rate increased 81.85% over the same period.  There can be many other factors at play in these three states such as differences in bankruptcy law.

Parts of the ACA were implemented in 2011 and there was a 10.79% (4.91 to 4.38 bankruptcies per 1000) decrease nationally from 2010 to 2011.  The slight decrease in the national rate could be due to slight improvements in the economy.  Mortality is a lot easier to measure than bankruptcy.

**Related Posts**

The Affordable Care Act Having an Impact in Some States but not Pennsylvania


 


National, State, & County Uninsured Estimates


 


The Affordable Care Act (ACA) having little effect on PA's Uninsured Rate So Far

 

An Explanation of Washington Post Graphs on the Cost of Procedures

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