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.

• It's too good to be true. The New York Times reports that experts are “skeptical of the magnitude and suddenness of the decline” in mortality. According to Dr. Joseph  Antos, a health economist at the American Enterprise Institute, “Health care is a much more involved process—you don't just sign up and suddenly get well.” This objection, of course, does not explain the results. These researchers may be overlooking the fact that being without health insurance is a psychological stressor, the removal of which may have widespread health benefits.

• 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."

You may also be interested in reading:

Health Insurance and Mortality, Part 1

Big News From Oregon:  Not All of It Good

The Coverage Gap:  The Real Failure of Obamacare

Romneycare:  The Bottom Line

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.

You may also be interested in reading:

Big News From Oregon:  Not All of It Good

The Coverage Gap:  The Real Failure of Obamacare

Romneycare:  The Bottom Line

A Nous la Liberte

Each week, Dr. Aaron Carroll, one of the bloggers at The Incidental Economist, releases a 5-10 min video called "Health Care Triage," in which he discusses current issues in health. This week's installment will be of special interest to single payer advocates, since it concerns the French health care system, which he considers the best in the world. You may not know whether to laugh or cry.

In previous weeks, Dr. Carroll has also discussed the Canadian system--not as good as France's, but much better than ours. He often discusses empirical issues, such as whether organic food is better for your health. If you sign up, You Tube will send you an e-mail each time a new video in this series is released.

You may also be interested in reading:

Conceptualizing Health Care Policy

Are You Feeling Lonely?

Outlier (noun): (1) a person whose residence and place of business are at a distance; (2) something (as a geological feature) that is situated away from or classed differently from a main or related body; (3) a statistical observation that is markedly different in value from the others of the sample.

The Organization for Economic Cooperation and Development (OECD) has released Health at a Glance, its 2013 report on the performance of health systems in its member nations. Here is one of the charts.

The vertical dimension is life expectancy in years. On the horizontal is health care spending per person in US dollars. The line is the curve which best fits the data. It has both a linear component—as health care spending goes up, life expectancy increases—and a quadratic component—as spending increases, each dollar spent has diminishing returns. The United States is an outlier. We are spending quite a bit more (about $2400 per person more) than any other country, but our life expectancy is 26^th out of the 40 countries, almost one year lower than the international average. Another way of looking at it is that the two countries closest to us in life expectancy, Chile and the Czech Republic, are spending less than a quarter of what we're spending per capita on health care.

We're spending lots of money, but not getting a good return on our investment. A substantial portion of the money is being spent not on improved health care services, but rather on ever higher profits for private insurers, drug companies, and giant hospital chains.

The next time a politician says we have “the best health care system in the world,” you are free to burst out laughing.

You may also be interested in reading:

Where's the Outrage?

Why Are American Health Care Costs So High?

Where's the Outrage?

Drs. Peter Ubel, Amy Abernethy and Yousuf Zafar, all medical doctors, published an editorial in The New England Journal of Medicine entitled “Full Disclosure—Out-of-Pocket Costs as Side Effects.” An abbreviated version by Dr. Ubel appeared as an op-ed in The New York Times as “Doctor, First Tell Me What It Costs.” They argue that, just as doctors typically discuss negative side effects of drugs and medical treatments with their patients, they should also discuss the financial cost of drugs and medical treatments before the patient makes a decision. These costs should be treated as a potential side-effects because stress from the threat of financial ruin can adversely affect the patient's health. They note that cost is sometimes not discussed because both patients and doctors are too embarrassed to bring it up.

Some examples of costly decisions are given.

• Bevacizumab (or Avastin), a drug which extends the lives of colorectal cancer sufferers an average of five months beyond chemotherapy alone, has a median price of $44,000. A patient on Medicare would be responsible for 20% of that cost, or $8800.

• A breast cancer patient with a high deductible health insurance policy faces average out-of-pocket costs of $55,000—obviously, more than the life savings of most Americans. A person with a high deductible plan faces a bill of $40,000 for myocardial infarction, and $4,000 per year for management of “uncomplicated” diabetes. (Meanwhile employers are increasingly shifting workers to insurance policies with higher co-payments and deductibles.)

The authors state four reasons it would be beneficial for doctors to inform patients in advance of the cost of treatment. My comments on each are in parentheses.

1. Informing the patient of the cost of treatment may cause some patients to switch to a less expensive alternative treatment that is just as effective. (Why would a doctor ever recommend a drug or treatment if there is an equally effective and less expensive alternative?)
2. Some patients may be “willling to trade off some chance of medical benefit” in exchange for lower cost. (This possibility, which the authors refer to as “complex and ethically charged,” gets to the heart of the matter. Some patients may choose to forego treatment rather than leave themselves or their families bankrupt. It is implied that knowing the full cost of treatment may persuade some folks to commit passive suicide.)
3. Patients could attempt to obtain financial assistance in advance of the treatment. (An example is given of someone who was able to obtain help from a charity—a rare event, at best.)
4. “A growing body of evidence” suggests that if patients take cost into account, it “might reduce costs for patients and society in the long term.” (However, there is no citation to this body of evidence and the authors do not elaborate. They may mean that if everyone became more cost-conscious, prices might come down, but does the health care industry operate the same way as other more competitive markets?)

It seems so obvious that doctors should discuss costs with patients that it hardly seems necessary for NEJM to publish an editorial suggesting that they do so. But the most revealing thing about this article is the issues Ubel and his colleagues don't even mention.

First of all, they don't ask why the costs of drugs and medical treatment are so much higher in this country than in other industrialized countries. Medical costs are treated as if they were merely an uncontroversial feature of the natural environment, and no mention is made of how they might be reduced.

My colleague Paul Ricci has blogged frequently—for example, here—about how we're spending much more per person on health care than other countries, and getting mediocre results. Ezra Klein has posted 21 graphs with comparative data on the costs of specific drugs and medical treatments. Medical bills account for over 60% of U. S., bankruptcies, and 75% of people with medically-related bankruptcies had health insurance.  A 2013 survey of 11 countries by the Commonwealth Fund found that Americans were more likely than residents of the other ten countries to forego health care because of cost and to have difficult paying for care even when they were insured.

There is some objective data comparing the causes of our higher prices. A 2012 study by the Institute of Medicine, a division of the National Academy of Sciences, estimated that the U. S. health care system wastes $750 billion a year, roughly 30% of the money spent. The report identified six major areas of waste: unnecessary services ($210 billion annually), inefficient delivery of care ($130 billion), excess administrative costs ($190 billion), inflated prices ($105 billion), prevention failures ($55 billion), and fraud ($75 billion). Our doctors are more highly compensated than doctors in the rest of the world. Our hospitals attempt to maximize their profits, regardless of whether they are legally registered as for-profit or nonprofit corporations. Part of the problem is political corruption. For example, when Congress expanded Medicare to include prescription drug coverage, Medicare was forbidden to use its purchasing power to negotiate for lower drug prices.

More importantly, the authors don't even question why it is necessary for so many Americans to choose between financial ruin and illness or death when they suffer from common medical conditions. They fail to mention that the rest of the world's developed countries have largely solved this dilemma by establishing government run single payer health care systems. If this were merely a matter of money, we could talk about the vast sums this country wastes on overseas military misadventures, or the way our billionaires grow increasingly rich while paying lower tax rates than their secretaries. But these outrages are irrelevant, since a single payer system will save money. All the countries with single payer spend less per capita on health care than we do.

To be fair, Ubel does say, “No one should have to suffer unnecessarily from the cost of medical care.” But he fails to pursue any of the implications of this remark. The authors never make the point that single payer would almost certainly solve many of the financial problems they agonize over in these articles. I suppose it's possible Ubel and his colleagues are secretly hoping to build momentum for single payer by encouraging doctors to empathize more with their patients, but there's nothing in the article to support this speculation.

To paraphrase a point frequently made by Noam Chomsky, no one becomes a tenured professor at an elite university, or is invited to write an editorial for The New York Times, unless he or she has completely internalized the world view of the ruling class, and in the process learned to ignore all the really important issues facing our society.

You may also be interested in reading:

Why Are American Health Care Costs So High?

New Time Magazine Article on Health Care Costs

Protecting the Parasites:  The Irony of Obamacare

Conceptualizing Health Care Policy

Mike Konczal has written an important article in which he asks: (1) What parts the Affordable Care Act (ACA) are not working well, and why?, and (2) What does this imply about future developments in health care policy? Will government abandon the effort to provide health care for all, or will we move toward a single-payer system?

Paul Krugman has described the ACA as a “kludge.” It is too complicated, and those complications are making the system inefficient and expensive, while depriving many Americans of health insurance. Konczal notes four specific problems:

1. The process of signing up for health insurance in the federal exchange (HealthCare.gov) is complicated because everyone must be means tested. The government must be able to confirm virtually every datum the applicants enter: their identity, their citizenship, their income, their eligibility for coverage through other federal or state programs, etc. All this is necessary to determine whether each applicant is entitled to a subsidy, and if so, the amount.
2. A further complication is that each applicant must be matched to a private insurer. The government must check that all of the thousands of insurance plans meet their minimum standards. They must clearly communicate the important characteristics of each policy to consumers, even though the insurance companies deliberately try to confuse them. They must contend with insurance company sabotage such as canceling plans abruptly and arbitrarily raising rates.
3. The ACA faces the threat of adverse selection—the possibility that the oldest and sickest among us will patiently navigate the exchange and eventually purchase a policy, while the youngest and healthiest will ignore the law and hope the penalty for not buying insurance is unenforceable. If Americans in poor health are more likely to buy insurance, the costs go up and there is a very real possibility that the system will collapse.
4. Finally, the federal government has to deal with attempted sabotage by states controlled by Republican governors and legislatures, exemplified by their refusal to set up state exchanges and to participate in Medicaid expansion, which is denying coverage to over 5 million low income Americans.

Summarizing these problems, Konczal describes two approaches to social insurance, which he calls Category A and Category B.

Konczal describes Category A as the “neoliberal” approach to public policy. Neoliberalism has, in recent years, become a synonym for conservatism. It refers to policies that reduce the role of government in public life through strategies such as privatization and deregulation. Category A social insurance sees the government as “an enabler to market activities, with perhaps some coordinated charity to individuals most in need.”

Category B, on the other hand, encompasses progressive programs such as the New Deal and the Great Society. It sees certain goods and services, such as food, shelter and health care, as basic human rights, and attempts to remove them from the marketplace by providing them to everyone.

There are very few pure examples of Categories A and B; most policies fall somewhere along a continuum between these extremes. However, the ACA falls clearly into Category A. This is not surprising because it is a plan devised by a conservative think tank which was promoted for decades by the Republican party. Social Security and Medicare, on the other hand, fall into Category B. Medicaid is a hybrid, since it is means tested and administered (and regularly sabotaged) by the states.

In the last three decades, we have seen a gradual rollback of Category B programs. This is not surprising, given the extent to which the political system is controlled by corporations and wealthy individuals. In the old days, the Republicans favored Category A and the Democrats Category B. As both parties have shifted to the right, the Democrats have shifted their allegiance to the Category A policies favored by their corporate donors, while many Republicans advocate eliminating social insurance entirely.

Whenever a public service is privatized, it moves from Category B to A. This is what happens, for example, when you turn over tax dollars to charter schools, so that corporations can make profits by educating children as cheaply as possible. Of course, the ultimate disaster for the country would be the Republican plan to privatize Social Security, since another Great Recession—a virtual certainty in the absence of financial reregulation—would have the potential to impoverish our elderly population.

PA Governor Tom Corbett's proposal to expand Medicaid would move this program further toward Category A through a combination of stricter means testing and turning the program over to private insurance companies. Our President, Dave Steil, has written an op-ed critizing the Corbett plan. He rightly notes the waste of money that would result from turning Medicaid over to private insurance companies. However, he overlooks the hardship that increased means testing, premiums and copayments will impose on working class Pennsylvanians.

Advocates of single payer health insurance—obviously a Category B program—are going to be urinating into a stiff wind for the foreseeable future. However, there is some hope. It is the four Category A characteristics noted above that are turning the ACA into a “kludge.” While Republicans will argue for repeal, pragmatists are likely to notice that if you drop some of these characteristics, you can improve health outcomes while saving money. And if you drop all four, you have single payer.

You may also be interested in reading:

The Coverage Gap:  The Real Failure of Obamacare

A Clouded Vision, Part 1:  The Stick

A Clouded Vision, Part 2:  The Carrot

Medicaid, Medical Insurance, Health Care and the Corbett Plan

UPMC Gives Pittsburgh the One-Finger Salute--Twice

UPMC, the largest member of Pittsburgh's health care oligopoly, whose fees are well above the national average, was in the news twice last week. The City of Pittsburgh is suing UPMC, which claims to be a non-profit, to strip it of its tax-exempt status. In a court hearing last week, UPMC claimed it does not owe any payroll taxes because it does not have any employees! (Although their website claims they have 55,000 employees, UPMC says these people are employed by subsidiaries.) So far, Judge R. Stanton Wettick, Jr., has not ruled on the credibility of this claim.

The Bombardier BD-700-1A10 Global Express

On Friday, it was learned that UPMC is spending $51 million on a new corporate jet plane, a Bombardier Global Express, described as “a luxury, ultra-long range business jet with twin Rolls Royce engines.” For security reasons, the flight plans of this airplane are to remain hidden from the public.

I'm sure Pittsburghers who are struggling to pay their medical bills will be thrilled to hear that UPMC is able to afford $51 million for a new stealth jetliner. But who is going to ride around on this luxury aircraft, since, as we now know, UPMC has no employees?

You may also be interested in reading:

Gekkonomics

It Ain't Over 'Til It's Over

Why Are American Health Care Costs So High?

Here's a 8-minute video by author John Green that repeats some arguments that are familiar to single-payer advocates, but in a very clear and concise way.

Bending the Health Care Cost Curve

On One Hand . . .

A Friday report from the Medicare Board of Trustees shows that there was a slowdown in the growth of Medicare costs in 2012. The Medicare trust fund is now projected to last until 2026, two years longer than previously estimated. Medicare spending is now growing at the historically low rate of 1.7% per year. Of course, a decline in the rate of growth doesn't mean the problem is solved. Costs are still going up. But at least they are heading in the right direction. The report attributes the decline in costs to a combination of the current recession, which is causing people to cut back on health care, and the Affordable Care Act (ACA).

Dr. Ezekiel Emanuel, one of the authors of the ACA, points out that there are two types of cost control embedded in the ACA, payment reductions and what he calls “structural and incentive changes.” The two primary payment reductions affecting Medicare are:

• Reduced payments for Medicare Advantage. Medicare Advantage allows seniors to purchase private insurance in lieu of traditional Medicare. It costs the government 14% more than Medicare even though it doesn't produce any better outcomes. That 14% is presumably being pocketed by the private insurance companies, and the government is taking it back.
• Reduced payments to Medicare providers, i.e., hospitals, home care agencies, etc. Emanuel says these organizations have profited from increased productivity in recent decades, but have not passed these savings on to the consumer. Therefore, Medicare is paying them less.

In short, the ACA made $716 million in automatic cuts to the Medicare program in 2012.  This chart shows that these two payment reductions account for the bulk of these Medicare cuts. They are the primary reason for the slowdown in the growth of Medicare spending.

The structural and incentive changes include things like bundled payments, where Medicare pays a fixed rate for an episode of care rather than fee-for-service, and Medicare's Independent Payment Advisory Board, which can make specific treatment recommendations in order to reduce excess cost growth. Most of these changes are several years away.

These cost controls are an important positive changes, since they have reduced costs without eliminating benefits to Medicare recipients. However, they're only a fraction of the amount that could be saved if the country were to move to a single payer system. First of all, they only affect Medicare, which insures 17% of Americans. Secondly, they are relatively modest cuts when you consider the excess profits currently being taken by hospitals and insurance companies.

The bottom line is that these data seem to show that the ACA is working in controlling Medicare costs, but it is only a modest first step compared to what we could and should be doing.

On the Other Hand . . .

Elisabeth Rosenthal has a long article in the Sunday New York Times about the high cost of medical care in the U. S., similar to the February Time feature by Steven Brill. Her article focuses on colonoscopies, presumably because it is a vivid metaphor for what the for-profit health care system is doing to all of us. However, her chart shows several common medical costs in which the average U. S. price tag is as much as 25 times higher than the price in other countries.

The sub-heading of the article says, “Colonoscopies explain why U. S. leads the world in health expenditures,” but they do no such thing. Merely listing the costs of medical procedures does not explain why those costs are so much higher in this country. Most of Rosenthal's argument is a tautology: Prices are high because prices are high. The closest she comes to offering an explanation is buried in the nineteenth paragraph:

A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor. Many other countries deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example.

Of course, she manages to make this point without mentioning the poisonous words “single payer,” which all the other countries cited in her article have. But the Medicare data show us what could happen if the government were to take a more active role in combating greed in the health care system.

You may also be interested in reading:

A New Time Magazine Article on Health Care Costs with Stewart Discussion

An Explanation of Washington Post Graphs on the Cost of Procedures

Medicaid Expansion Update

Legalized Bribery

Big News From Oregon--Not All of It Good

There is study in progress with a randomized control group design—the gold standard of evaluation research—to evaluate the effects of Medicaid expansion in Oregon. The second wave of results from that study were published yesterday. To summarize briefly, Oregon wanted to expand Medicaid but didn't have enough money. They invited anyone who was eligible to apply, and 90,000 people applied. They then randomly selected 10,000 of them to receive Medicaid, while the others became eligible for the control group. The first wave of results, with about 6000 adults in each group, showed that the Medicaid recipients were more likely to rate themselves in “good” or “excellent” health, were less likely to report a recent decline in their health, had more doctor and hospital visits, more preventive care, and fewer unpaid medical bills.

Unfortunately, the second wave study, published in the New England Journal of Medicine, is gated, so I am relying on the abstract and a summary by Aaron Carroll and Austin Frakt in The Incidental Economist blog.

The corporate media are spinning the second wave study as showing Medicaid expansion to be a failure. For example the New York Times says:

It found that those who gained Medicaid coverage spent more on health care, making more visits to doctors and trips to the hospital. But the study suggests that Medicaid coverage did not make those adults much healthier, at least within the time frame of the research . . .

Later the article notes that Medicaid expansion under the Affordable Care Act will be costly. “Health economists anticipate that new enrollees to the Medicaid program will swell the country's health spending costs by hundreds of billions of dollars over time,” it warns. If you go online and check the comments following any article about the study, you'll find that it has unleashed a torrent of criticism from the political right claiming that providing health care for the poor is a waste of money. The study is certain to be used by Republicans such as Pennsylvania Governor Tom Corbett to justify their opposition to Medicaid expansion.

So what does the second wave study actually show? First, the bad news. The three objective indicators of physical health, blood pressure, cholesterol and blood sugar level, were all lower in the Medicaid group than the control group, but the differences were not statistically significant. Here are the data. (HDL is “good” cholesterol, so the fact that there are fewer people with low HDL cholesterol in the Medicaid group is a good outcome. High hemoglobin A1c is high blood sugar.)

Now the good news. Medicaid reduced the incidence of depression by 30%, which was statistically significant. It also significantly increased preventive care, including a 50% increase in cholesterol monitoring, a doubling of mammograms, and an increased likelihood of being diagnosed with diabetes.

Finally, the economic news. Health care spending was 35% higher in the Medicaid group. Of course, Medicaid practically eliminates catastrophic medical costs. As a result, the Medicaid recipients were significantly less likely to report borrowing money or skipping other bills in order to pay medical expenses.

There are several reasons we should not accept the conservative rush to judgment that this study shows that Medicaid is not helpful.

• Medicaid recipients were healthier on all three measures of physical health. The problem is that the differences were not statistically significant. There are several reasons why that might be the case, but the most likely is that the sample sizes were too small to detect the effect. The authors state:
  
  
  [O]ur power to detect changes in health was limited by the relatively small numbers of patients with these conditions; indeed, the only condition in which we detected improvements was depression, which was by far the most prevalent of the four conditions examined. The 95% confidence intervals for many of the estimates of effects on individual physical health were wide enough to include changes that would be considered clinically significant . . .
  
  
• These data were collected only two years after the program began. The significant differences in preventive care suggest that greater differences in health might emerge in later waves of the study.
  
  
• Mental health is also health, and significant differences in depression should not be dismissed as unimportant. Financial hardship also matters, and its absence may be related to the lower incidence of depression in the Medicaid group.
  
  
• There is no comparable study of the health effects of private health insurance, so these data should not be used to infer that Medicaid is any more expensive or less effective than private insurance.
  
  

Let's do a thought experiment. Suppose you had a private health insurance policy, researchers did a study to evaluate its health effects that was comparable in size, duration and design to the Oregon study, and obtained identical results. That is, the policy holders' health was better, but not significantly better than people without insurance. Would you cancel your policy? One of the reasons people buy health insurance may be that they think it will make them healthier, but it is my guess that the primary reason people in this country buy health insurance is to guard against the financial consequences of catastrophic illness.

You may also be interested in:

Tom Corbett to PA's Working Poor: “Drop Dead!” Part 1. Medicaid improves Health and Saves Lives.

Tom Corbett to PA's Working Poor: “Drop Dead!” Part 3. What Medicaid Expansion Would Mean to Pennsylvania

Medicaid Expansion Update

My life was threatened by the multi-company, private health insurance system we currently have (repost from Joanne Tosti-Vasey's Blog)

Healthcare for All PA state Board Member and past PA Now President has written an article in http://civilrightsadvocacy.net/ on her own personal struggles with the insurance industry.  It is reposted here with her permission.  The name of the blog has changed to Healthcare for All PA PUSH to reflect that we are a chapter of the statewide organization.

Congressman John Conyers Jr. (D-MI) has reintroduced his National Health Care plan bill HR 676, “The Expanded and Improved Medicare for All Act.” I strongly support a universal national health care program such as HR 676. I also support any effort by any state to implement a state-based single-payer health care plan. Why?  For many reasons.

My life was threatened by the multi-company, private health insurance system we currently have.

I received a bone marrow transplant in 1989 from my identical twin sister. Although I had no problem finding a match, I had to jump through many hoops and barriers put up by the two health insurance companies covering my sister and myself. In the case of my insurance provider, I was refused coverage of the donor portion of the transplant because my twin sister wasn’t on my health insurance plan. In the case of my twin sister’s insurance provider, they refused to cover her portion of the transplant because she “wasn’t sick.” Then the hospital administration said that they would not perform the transplant until this conflict between the two insurance agencies was resolved with a guarantee of payment by either or both companies. And my doctors said that if the resolution did not occur rapidly, I would be dead within the year due to the seriousness of the form of leukemia that I had.
According to Health Care for America, health insurance companies profit by denying–not by providing–healthcare. Health insurance CEOs of the top 10 health insurance companies today typically enjoy an average of $10,000,000 in annual compensation–salary, bonuses, stock options, etc.

Back to my story. I went into battle mode against the insurance companies when I was told that they would let me die because of their bottom line and attempts to deny coverage. Because of the support and advocacy I had through the organization where I self-purchased my health insurance (the National Organization for Women), we were finally able to get me the life-saving transplant that I needed. And I am here today.
This experience is why I became an advocate for a single-payer health care system rather than the current system that allows private companies the ability to deny critical health care to “save” their bottom line for profit only.

Other Reasons why I support a Universal Health Care Plan at Either the National or State Level.

It is the ethical and moral to treat all people, regardless of economics or status when they are sick.

A 2009 article in the Journal of Public Health reports that approximately 45,000 people on average die each year due to lack of health insurance. One of the goals of The Affordable Care Act (ACA) is to reduce the number of people without health insurance, so that premature deaths from lack of coverage would also be reduced.
People will continue to struggle to receive health care coverage and treatment with both passage of the ACA and the Supreme Court’s decision declaring the ACA as constitutional while allowing states to opt out of the expanded Medicaid program for low-income people.
The Centers for Disease Control acknowledges that access to coverage will improve under the ACA. But that acknowledgement holds a caveat; they state, “Even after ACA is implemented fully, some persons eligible for coverage might go uninsured.” The ACA will not fully resolve this ethical and moral threat to peoples’ lives. 

Some states are threatening people’s health care and lives based on decisions either by their legislature and/or their governors.

These states place people who could have been covered under the Expanded Medicaid program in continued jeopardy since they will neither be able to sign up for Medicaid nor be able to afford private health insurance through the ACA’s health care exchanges. The 13 states that have already threatened the healthcare of their citizens are Alabama, Georgia, Idaho, Louisiana, Maine, Mississippi, North Carolina, South Carolina, South Dakota, Oklahoma, Pennsylvania, Texas, and Wisconsin. Five states – Iowa, Nebraska, New Jersey, Virginia, and Wyoming—are leaning towards opting out of coverage. Kentucky, New York and Oregon haven’t yet made their decision, but do appear to be leaning towards opting into full ACA with the expanded Medicaid coverage. All remaining 22 states plus the District of Columbia have opted into full ACA with the expanded Medicaid coverage.


Via: The Advisory Board Company
For the low-income people living in the 18 states that have either opted out of or are considering opting out of the expanded Medicaid coverage, nothing changes for them since most of these individuals will not be able to afford private health insurance in the new health care exchanges under the ACA.

A Single Payer, Universal Healthcare program would cover everyone.

According to predictions by the Congressional Budget Office and the Joint Commission on Taxation, we will we still have 30 million uninsured in 2023 under Obamacare. At the same time, health care costs for our nation, states, and families will continue to increase. A single-payer, universal healthcare program could cover everyone at lower cost. Everyone in and no one out regardless of income or health status.

The BETTER Alternatives: National and State-Based Single-Payer Plans

The plan introduced by Representative Conyers is basically an expansion of the efficient and cost-effective Medicare system currently used by the elderly and people with disabilities. Its overhead (all costs other than for healthcare) is much lower–and patient satisfaction is much higher–than under for-profit healthcare. And it would cover everyone regardless of their economic or health status without fear of an insurance company denying coverage to save their bottom line.

Similarly, legislation is being considered in about half of the states to create state-based single-payer healthcare programs. Some of these states’  legislatures have held hearings and/or had votes on universal healthcare. Vermont has already passed a law that sets in place the possibility of a single-payer healthcare program by 2017. 2017 is the year that the ACA—aka “Obamacare”—allows states to try other healthcare plans IF they cover at least the same number of people with at least the minimum coverage under the ACA.
Obamacare is now the law of the land. It is an improvement over what we had before 2009. It is also the basis from which we can work towards a comprehensive healthcare program. We could do it nationally, such as with HR 676. Or, like Canada, we can start at the state level.

So check out HR 676. See if your Representative is one of the 40 current co-sponsors. If not, meet with him/her, tell your personal story about why you support an expanded and improved Medicare for All, and ask them to co-sponsor the bill. If he/she is already a co-sponsor, ask your Representative to take the next step. They can hold a town-hall meeting on universal healthcare to hear from their constituents. They can also call on the chairs of the three committees reviewing HR 676 to hold Congressional hearings on HR 676. These three committees are the House Energy and Commerce Committee, the House Ways and Means Committee, and the House Natural Resources Committee.
Also get active with your state-based single-payer organization. These local and state-based single-payer health care groups will let you know how can help with your state-based legislation. Healthcare NOW has a full listing of state- and local-based organizations. If your state does not have a single-payer chapter yet, contact Healthcare NOW at their national office in Philadelphia, PA; they can help you to organize a plan for your state.

All other “advanced” nations have already adopted comprehensive healthcare systems. All deliver better health outcomes at a lower per capita cost than the USA. Let’s get cracking. Let’s do it here in the US of A as well.

**Related Post**

Joanne Tosti-Vasey's Bone Marrow Transplant Story