w-medicaid2

Ezra Klein takes the long view of the Oregon Health Study, which showed little to no improvements in health among Medicaid enrollees over a two-year period:

[T]he study was simply too small, with too few sick people, to show the kind of quick health changes the researchers were looking for. Sharply increasing the number of people who are managing their diabetes and mental health, getting colonoscopies and mammograms, and making regular trips to the doctor sure seems like the kind of thing that will improve long-term health outcomes. Other studies with a less rigorous — but still credible — design and a longer timeframe have shown that states that expanded Medicaid saw a six percent drop in death rates among the newly insured group. …

I’ve seen my doctor a few times over the last two years. None of those visits had any measurable impact on my health. But if something had been wrong on one of those visits, the story would be very different. I have health insurance not because it improves my health on any given day, but because regular access to the medical system will, presumably, improve my health over time.

I get that. But if expanding Medicaid does not make people measurably healthier, the cost and benefit equation needs reviewing. I do think the study needs replicating and needs to be undertaken on a longer time scale. But, as it stands, it’s a strong argument for universal catastrophic insurance, which includes mandatory check-ups for preventive care. Drum takes issue with the study’s methodology. Beutler’s criticism:

[The] Oregon study was not designed to address the excess deaths issue, just like studies on insurance’s impact on mortality aren’t designed to test its impact on various health measures across the population. But of course, most real-world excess death studies link tens of thousands of deaths a year to uninsurance. That’s a very small percentage of the millions of uninsured in the United States. But I doubt even Medicaid’s loudest critics would shrug off 10,000 or 20,000 preventable deaths a year in most other contexts.

Chait responds to the digs from conservatives:

Okay: The case for Medicaid expansion is not as strong as I had thought. Now for the caveats: The case for Medicaid expansion is overwhelmingly strong. If a study found that puppies survive steep falls at a higher rate than expected, then you could say the case for throwing puppies out of skyscraper windows has marginally weakened, but would remain extremely strong. Indeed, data notwithstanding, either throwing puppies out of skyscrapers or throwing people off Medicaid are both acts of sadism.

The United States has very high levels of income inequality, a very stingy welfare state, and is the only advanced economy that does not guarantee access to medical care. The Oregon study does not raise particular questions about the efficacy of Medicaid; it raises questions about the efficacy of medical care in general. Measuring the impact of medicine is just really hard to do, yet almost nobody would volunteer to follow this frustrating fact to its logical conclusion and forgo the benefits of modern medicine.

Yes, but since Medicaid is paid for entirely by others, it seems only fair that they be persuaded that it’s actually value-for-money. Douthat’s take on the study:

[I]f it turns out that health insurance is useful mostly because it averts financial catastrophe — which seems to be the consensus liberal position since the Oregon data came out — then the new health care law looks vulnerable to two interconnected critiques.

First, if the benefit of health insurance is mostly or exclusively financial, then shouldn’t health insurance policies work more like normal insurance?

Fire, flood and car insurance exist to protect people against actual disasters, after all, not to pay for ordinary repairs. If the best evidence suggests that health insurance is most helpful in protecting people’s pocketbooks from similar disasters, and that more comprehensive coverage often just pays for doctor visits that don’t improve people’s actual health, then shouldn’t we be promoting catastrophic health coverage, rather than expanding Medicaid?

Liberals don’t like catastrophic plans because, by definition, they’re stingier than the coverage many Americans now enjoy. But this is where the second critique comes in: If the marginal dollar of health care coverage doesn’t deliver better health, isn’t this a place where policy makers should be stingy, while looking for more direct ways to improve the prospects of the working poor?

He puts the point delicately, but it’s a very powerful one, it seems to me. Pete Spiliakos builds on Ross’ recommendations:

Republicans could argue for moving health care financing to a model of catastrophic health insurance coverage, plus coverage for routine preventive care, plus health savings accounts to pay for non-catastrophic health care costs. James Capretta has been working on this [pdf]. Republicans would be able to plausibly argue that their plans would maintain the health care security of middle-class families while reducing health care premiums and expand health insurance coverage for low-earners at lower cost to taxpayers than Obamacare. Republicans can be the party of health care security and more take home pay and lower spending. C’mon people. You can do this.

If we had a sane and pragmatic GOP, this would have been the critique in the first place, together with a program for national catastrophic insurance on the lines Spiliakos suggests. That would have elevated and deepend the debate all round – but ideology and partisanship obscured it. Barro believes the Oregon report reveals insight into a key weakness of the ACA:

Obamacare relies mostly on bureaucratic approaches to achieving cost control. … [Liberals] are right to note that conservatives’ preferred alternative to Medicaid expansion (leaving tens of millions of people uninsured) would be worse for quality of life. But the lesson of the Oregon Health Study is nonetheless that there’s cost-effectiveness information out there that Medicaid and other health insurers aren’t exploiting. And even though conservatives have generally done a terrible job of explaining why, conservative ideas about increasing consumer direction in health care could help to exploit that information and make health care more cost-effective — without repealing Obamacare or stopping the Medicaid expansion.

I have become far less confident that patients can act as real consumers in the healthcare marketplace. There’s such an imbalance of knowledge and the consumer is almost always desperate for a solution, with no leverage to bargain with. Meanwhile, the Florida legislature just adjourned without providing funds for a Medicaid expansion, “join[ing] 24 other states that have either decided against expanding Medicaid, or are leaning in that direction, according to analysts at Avalere Health [who created the above chart].”