What the Oregon Medicaid study said: access to healthcare is good for you

Posted by AzBlueMeanie:

Wingnuttia is all atwitter over an Oregon Medicaid study that they claim demonstrates that Medicaid does not improve the health of people on Medicaid. So I assume their points are to say that "Medicaid doesn't work" so "you are on your own" and if you are seriously ill perhaps you "should die and decrease the surplus population."

This is what happens when GOPropagandists — who did not read this complex research study because, really, who cares? — are paid to push simpleton bumper sticker memes about the evils of "socialized ObamaCare."

So before you get buried under a mound of bullshit from wingnuttia in the battle over Governor Brewer's Medicaid restoration/expansion plan, here are some articles to help you sort out fact from GOPropaganda.

First, Ezra Klein explains, Here’s what the Oregon Medicaid study really said:

The Oregon Medicaid experiment is an academic miracle born out of a human tragedy.

A few years back, Oregon found the money to add 10,000 residents to
the state’s Medicaid program. The only problem was that there were
90,000 residents who qualified for the program and desperately wanted
in. So the state held a lottery. Welcome to the American health-care
system. Greatest in the world, folks.

But 80,000 Oregonians’ loss was science’s gain. The lottery gave
researchers an opportunity that’s almost never available in
policymaking: They could create a randomized controlled study — the
absolute gold-standard of experimental design — comparing the health
outcomes of the lucky Oregonians who received Medicaid to those who
didn’t. It would be the first time that kind of study had even been used
to compare the insured and the uninsured.

The initial batch of results was released in August 2012. The data
covered the first year of the Medicaid expansion and found that the
folks on Medicaid were getting more care, reporting better health (both
physical and mental), and seeing fewer financial problems than the
people who weren’t on Medicaid.

The second set of results was
released Wednesday. The data now covers two years and, importantly,
includes clinical measures of health rather than relying on the reports
of the study participants. These results are more mixed, but also more
telling.

Here’s what we can say with certainty: Medicaid works as health insurance.

* * *

[T]he Oregon residents who won the Medicaid lottery got much more
health care — including preventive health care — than the residents who
lost it. They also saw catastrophic health costs basically vanish.

“People who gained access to Medicaid did use more health care,” says
Harvard’s Katherine Baicker, one of the study’s authors. “We can
eliminate the story that Medicaid is so lousy you can’t get in to see a
doctor.”

But the study didn’t see much improvement in the health indicators it
was tracking.
Blood pressure and cholesterol readings were mostly
unchanged. Diagnosis of diabetes went way up, and the use of medicine to
control diabetes also went up, but, again, there wasn’t much difference
on the relevant blood tests. The big exception, surprisingly, was
mental health: depression rates fell by 30 percent.

So here’s what happened in the first two years of the Oregon Medicaid
experiment: Medicaid proved itself good health insurance
. The people
who got Medicaid used more health care, and seem to have done so smartly
— they got preventive care, they got their diabetes diagnosed and began
managing it, treated their depression, and so on. But the health care
itself didn’t work as well as we hoped — at least not in terms of
cutting rates of hypertension and cholesterol.

There are a number of possible spins you can put on that finding. One is
that the study was simply too small, with too few sick people, to show
the kind of quick health changes the researchers were looking for
. . . 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.

Another is that the Medicaid enrollees are getting bad health care —
but there’s no actual evidence for that argument. In fact, the study
mostly seems to blow up that argument. [Paging Dr. Kelli Ward (R-Lake Havasu City) – your talking point is B.S.]

* * *

A third and more radical interpretation is that health care — or at
least the kind of routine health care insurance buys you — simply
doesn’t work that well
. After all, it’s not as if the Oregon study
contradicts past randomized studies pitting the insured against the
uninsured. It’s the only study of its kind. In that way, it’s a unicorn.

My view, after speaking with a number of the study’s authors and outside
experts, is a mixture of one and three. There’s voluminous evidence
that managing diabetes and treating depression and being able to go to
the doctor improves health. You have to be willing to throw quite a lot
of existing theory and evidence out the window to believe that stuff
won’t pay off down the road.

* * *

The problem with the Oregon study is that it doesn’t help us figure out
how to make health care or health insurance better. We don’t know if the
results speak to the health care you get through all health insurance
or just Medicaid or if they’re just an artifact of the study’s timeframe
and sample size. We don’t know if different ways of designing insurance
programs would lead to radically different care outcomes (we actually
tried a randomized study on that question in the 70s, and the answer,
at least then, was “not really”). And so we don’t know whether we’re
seeing a problem in Medicaid, an inconvenient truth about medical care,
or something else. Worse, we don’t know what to do next.

Ed Kilgore at the Political Animal blog comes to the same obvious conclusion as Ezra Klein,
Health Care Is Probably Good For Your Health:

Kevin Drum, bless him, won’t let go of the Oregon Medicaid study, which, the more you stare at it, doesn’t much “prove” what conservatives say it proves:

[I]t turns out there were improvements in blood pressure,
glycated hemoglobin, and cholesterol, but the size of the study was
fairly small, so the results weren’t statistically significant.
Specifically, as Sam Richardson tweets, “#Oregon point estimates:
Reductions of 30% in depression, 18% in high HbA1c, 17% in high chol, 8%
in high BP. Big effects, little power.”

“Proving no positive health outcomes” (even if you ignore the very
positive finding about the impact of Medicaid on depression) is a very
different thing from finding improved health outcomes in a sample so
small that you can’t deem them as “statistically significant.”

But here’s the bigger issue Kevin raises:

The truth is that if you take a narrow view of “outcomes,”
it’s hard to find a significant effect from most of our healthcare
efforts. Nonetheless, improved access to Medicaid produces plenty of
improvement in acute problems; better use of preventive care; and far
better financial outcomes. This is all worthwhile stuff even if
controlling chronic conditions remains a challenge.

Overall, I’m a little unclear about what the conservatives
who are crowing over this study really think. They obviously believe
that access to healthcare is a good thing for themselves. (At least, I
haven’t heard any of them swearing off doctor visits.) But you can’t
have it both ways. If it’s a good thing for us middle-class types, it’s a
good thing for poor people too. Conversely, if it’s useless for poor
people, then it’s useless for the rest of us too. So which is it?

If something about Medicaid itself is the problem here, then what’s
the alternative? Insurance poor people can’t afford for crappy coverage
in high-risk pools? Reliance on hospital emergency rooms for expensive
acute care the rest of us pay for? Most of those who are using a
cartoon version of this study to provide a talking point for screwing up
the implementation of Obamacare probably aren’t thinking about
alternatives at all.

Finally, Greg Sargent writes in A war over Medicaid:

As you may have noticed, an internet brawl has broken out over a New England Journal of Medicine study of Oregon Medicaid recipients that has gotten caught up in the larger battle over Medicaid expansion in the states. Jonathan Cohn has already done a better job than I ever could of summarizing what the study finds and what both sides are claiming about it, so go read him first.

The short version is that conservatives are seizing on the finding
that recipients showed no significant improvement in health to stiffen
the spines of Republican state officials who are considering not opting
in to Obamacare’s Medicaid expansion. Liberals, meanwhile, are
acknowledging that finding, while also noting that it found Medicaid
produced a sharp drop in depression rates and in catastrophic
out-of-pocket medical expenditures.

I emailed one of the authors of the study, Amy Finkelstein, a
professor of economics at MIT, for her take on the battle. She declined
to take sides but said something that’s useful in thinking about this
fight:

“The results of our randomized evaluation of Medicaid are
mixed. Looking over the first two years, we do not find evidence that
Medicaid significantly improves measured physical health. However, we do
find that Medicaid substantially reduces rates of depression, and
virtually eliminates catastrophic out of pocket medical expenditures.
How you interpret these findings depends in large part on what you think
is the goal behind Medicaid coverage.”

* * *

Meanwhile, another author of the study, MIT’s Jonathan Gruber (a big
proponent of Obamacare), says the mental health improvement — in which
depression rates dropped by one-third — should not be underestimated.
“This is an astounding finding — that is a huge improvement in mental
health,” he told TPM.
“I would view this study as somewhat weakening the argument for
universal coverage based on health improvements, and greatly
strengthening the argument based on financial security and mental well
being.”

The larger story here is that a number of GOP-controlled states are still trying to determine whether to opt out of the Medicaid expansion,
something that will have significant long term implications as to how
well Obamacare works. In a victory for the law, West Virginia announced
today that it would opt in.

Unless economic security and improved mental health are suddenly not
to be seen as goals of Medicaid, it’s hard to see how this new study
does all that much to undercut the case for continuing to expand
coverage.

Better know your memes when fighting GOPropaganda.

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