• Oregon Medicaid experiment “is a Rorschach test of people’s views of the ACA”

    Wednesday’s New England Journal of Medicine article on the Oregon Medicaid lottery has provoked a firestorm of reaction. I’m not sure what I can add after reading Austin and Aaron’s great posts. They’re just killing this one.

    I’m now pondering the Supplementary Appendix prepared by the study team. It’s a pleasure to view the craftsmanship and clarity on display there. Many people are reading this study with an eye towards the big-ticket questions of the Affordable Care Act. I believe that’s a mistake. The moral and pragmatic case for expanded health coverage was overwhelming before these Oregon findings were released. That case is no less overwhelming now.

    As Aaron and Austin recount, Oregon Medicaid lottery winners were markedly less likely to face catastrophic medical bills or endure other forms of financial distress. Lottery winners were more likely to report that they received high-quality medical care through a usual provider who met their treatment needs. Medicaid recipients in the experiment were nine percentage-points less likely to satisfy screening criteria for depression, a 30% decline in the base rate. Lottery winners over age fifty were markedly more likely to receive mammograms, Pap smears, and other preventive services. People were more likely to receive depression or diabetes medications.

    So Medicaid coverage brought substantial benefits. Indeed the program compares surprisingly well with Medicare and with private insurance in providing effective coverage for low-income adults. Were these benefits worth the additional $1171.63 per-person annual Medicaid costs? I believe the question answers itself.

    Yet the case for Medicaid expansion is not the only or the most interesting question in-play here. Distinguished Harvard economist Joseph Newhouse emailed that the Oregon study “is a Rorschach test of people’s views of the ACA.”

    That’s perhaps unavoidable. It’s unfortunate, too. One sad consequence of polarization is our reflex to interpret every finding in light of its polemical utility in the broader political fight.

    I’m not one to throw stones over partisan attachments. Yet the partisan lens often obscures what’s most instructive about excellent, complex, and in-some-ways limited studies. The view becomes especially murky because the Oregon study is so under-powered to examine the physical health outcomes of greatest concern.

    The most obvious power problems arise because most Medicaid lottery winners never actually enrolled. As the Oregon researchers described in the Quarterly Journal of Economics, lottery winners were mailed an application and given 45 days to submit the appropriate paperwork establishing Medicaid eligibility:

    About 30% of selected individuals successfully enrolled. There were two main sources of slippage: only about 60% of those selected sent back applications, and about half of those who sent back applications were deemed ineligible, primarily due to failure to meet the requirements of income in the last quarter corresponding to annual income below the poverty level, which in 2008 was $10,400 for a single person….

    Lottery winners and controls sometimes obtained other coverage. Life intruded in other ways. All-in-all, winning the lottery was associated with a 25 percentage-point increase in actual Medicaid receipt.

    Second, the study team lacked baseline clinical measures. So they could not specifically control for baseline health. They could segment the analysis into patient subgroups based on age or other factors. When researchers tried to drill down to these subgroups, they didn’t see much, but the confidence intervals were also very wide.

    Consider the issue of high blood pressure. Baicker et al. reported no statistically significant reduction in hypertension. That’s disappointing, especially in light of the 1974-82 RAND Health Insurance Experiment, which found important predicted mortality reductions among low-income participants who began the study in ill-health. But the Oregon experiment was only a two-year study. It lacked the sample size and baseline data to properly replicate this analysis.

    To give you a sense of the challenge, Oregon Medicaid receipt was associated with an estimated increase of 1.76 percentage points in new diagnoses for hypertension. Since the control group mean was 5.6 percent, Medicaid receipt was associated with a 30% increase in the detection of previously undiagnosed hypertension within a relatively short period.

    That’s not statistically significant, but it’s potentially quite important. Unfortunately, it’s inherently difficult to tease out such a small effect. For all the thousands of study participants, back of the envelope calculation indicates this corresponds to something like 33 more detected cases within the treatment than the control group.

    Ironically, the overall population effect on hypertension seemed quite similar in the Oregon experiment and the RAND HIE. Free care within the original RAND HIE induced a (non-significant) reduction of 0.7 mm Hg in diastolic BP. In Oregon, Medicaid receipt was associated with an (also non-significant) average reduction of 0.81.

    I believe that a longer intervention with a larger sample will yield real, though modest health impacts on hypertension, diabetes, and other conditions. The abstract to the New England Journal study states: “Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years.” That’s correct, but easily misleading given the power limitations and some promising preliminary results.

    I believe both ideological camps in American health policy should probably gain some comfort, and some discomfort, from these results. Medicaid absolutely helps people. There’s an OJ-searching-for-the-real-killer quality to arguments against health reform that claim otherwise.

    Yet the critics are right that simple Medicaid enrollment failed to powerfully move the needle on basic cardiovascular measures as much as many of us hoped it would. Public insurance can and must do better in these areas.

    Medicaid could certainly do a better job promoting individual health. Some issues are pretty basic. The original RAND HIE found that patients were particularly price-sensitive in their demand for dental and vision services.* Low-income participants in the RAND Health Insurance Experiment assigned to free care could see better, and had better oral health than their peers assigned to cost-sharing plans.

    These lessons should be more consistently applied. Like many other states, Oregon doesn’t cover non-emergency dental services or vision care in its Medicaid program. Covering these services would bring immediate health benefits. Expanding such coverage would also engage people who have other difficulties such as undetected cardiovascular difficulties.

    As in the original RAND Health Insurance Experiment, there’s no evidence that Oregon’s Medicaid enrollment improved health behaviors. Indeed Medicaid receipt was actually associated with increased smoking, presumably because lottery winners had increased disposable income.

    Expanded Medicaid coverage is essential. Yet it’s only the first step to improved quality of care and improved population health. Improved disease management, accountable care organizations, and primary care medical homes are important, too. So are measures such as work-based wellness programs, smoking cessation programs, alcohol, and tobacco taxes to address public health concerns.

    The Oregon research team should be proud of what they’ve accomplished. Their findings underscore the immediate benefits of health reform, but also how much work we still must do.

    *The Affordable Care Act fills many holes in the areas of mental health and substance abuse services, too. That’s a topic for another occasion.


    • Conservative policy analysts and bloggers would not be negative on left leaning commentary and impressions if posts like yours–which I like very much–had the date 5-4-10, and began with, “I think the Oregon study might show “x.”

      Rather, they feel if the study was markedly positive, all pro-ACA individuals would be crowing. The ex-post analysis and backing into findings irks them, and turns the Rorschach tug-of-war into a tribal fight. They have a point. I might be doing the same in a 180 degree world.

      The importance though depends on the intellectual honesty of the writer. Here, I have no quibbles.


    • The ACA itself is a Rorschach test, seen through the lens on how one will personally benefit financially, either by income or health insurance savings, and how much one is likely to toe the party line and want to see Obama as a success.

      If you are a 60 year old married self employed rabid Obama hater with limited income, moderate assets, and pay $25,000 a year for insurance and copays, your rabid hatred of Obama is lessened by the significant economic benefit.

      If you are a “liberal” you ignore the cost of healthcare, the bankruptcies, and the poor results compared with other countries, and are comforted that Obama is better than Bush while by most metrics except your stable government subsidized salary and the QE supported stock market, the country devolves and the GINI coefficient goes through the roof (along with the associated corruption).

      But we can rest assured that at least where there is Medicaid, there is Medicaid.

    • “Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years.” That’s the authors’ conclusion, not the result of the study. I appreciate that Pollack, Carroll, and Frakt don’t wish to make matters worse by criticizing the authors of the study, but why did the authors include such a provocative conclusion in their report. A conclusion that I don’t believe can be made from such limited “measured physical outcomes”. And the conclusion is provocative because most people read only that one statement (it’s not even the complete sentence taken from the conclusion in the abstract) and, moreover, most people don’t appreciate the significance of “measured” or the distinction between results and conclusions. Experts like Pollock read the entire report and do so by applying an expert’s critical (i.e., careful) analysis. The report and the reception it is getting are important not only for the political consequences; they could affect the willingness/motivation of the uninsured to seek coverage from Medicaid expansion or subsidized insurance through the exchanges. “The Oregon research team should be proud of what they’ve accomplished.” Pollack must be a southerner to be so polite.

    • $1,171 per person?

      That seems awfullty low. I assume this was comprehensive insurance, not a minimed policy with low annual limits

      The ACA subsidies assume that a policy that is more restrictive than Medicaid and has real deductibles will cost $4000-$5000 per person.

      I am puzzled.

      • The $1,171 doesn’t seem terribly low. Here are the Canadian per capita costs to provincial governments in 2012, providing broadly similar health care services as Medicaid (no dental, limited or no pharma, limited psych) with zero co-pays or deductibles. The major difference is that provinces cover evferyone, including high cost seniors who would generally have coverage in the U.S. under Medicare.

        “Provincial and territorial governments are forecast to spend $135 billion in 2012, accounting for 65% of total health expenditure in the country. Provincial and territorial government health care spending continues to vary by province, with spending per person expected to be highest in Newfoundland and Labrador and Alberta, at $5,190 and $4,606, respectively. Quebec and British Columbia are expected to have the lowest health expenditure per capita, at $3,513 and $3,690, respectively.” http://www.cihi.ca/cihi-ext-portal/internet/en/document/spending+and+health+workforce/spending/release_30oct12

        “In 2010, the latest available year for data broken down by age group, per person spending for seniors increased with age: $6,223 for those age 65 to 69, $8,721 for those 70 to 74, $12,050 for those 75 to 79 and $20,113 for those 80 and older.” (I believe these are 100% costs, not the 65% funded by provinces and territories.)

    • What the Oregon study showed is this:

      — There is a limit to what medical care can do to improve a person’s
      (or a population’s) health.

      If you study premature death in the U.S., you find that poverty, your environment, and whether you smoke, drink to excess or use drugs are significantly more importantly than access to health care.
      As Dr. Steve Schroeder pointed out in a landmark Shattuck lecture in 2007:
      “:When compared to poverty, medical care plays “a relatively minor role” in premature deaths.”
      Scroll down to the pie chart in his article, and you’ll see what he is talking about http://www.nejm.org/doi/full/10.1056/NEJMsa073350

      Poverty is the most important factor leading to poor health and premature death. Poor people are much more likely to smoke, drink to excess or use drugs becaause the stress of being poor it leads to anxiety,
      depression , despair and anger. These people are self-medicating.
      The poor also are more likely to live in a pollluted environment
      and are less likely to have a safe place to exercise.

      Particularly when you are looking at diseases like diabetes or high blood pressure I would not expect that access to health care for two years
      would undo the harm (both psychological and physical) done by poverty.

      Of course this is not an argument against expanding Medicaid and giving everyone access to heatlhcare.

      But we should be aware that if we want to improve the population’s
      health, that is just a first step.

      The next step is to invest in public health. That would mean launching a new War on Poverty. We tend to exaggerate what medical care can accomplish–and ignore public health.

    • Let me carry Maggie’s points a little further.

      The first responsibility of government in health care is to deal with contagious diseases That sounds obvious but only because America has made great progress in this area over the last century.

      A second responsibility of government is to provide or subsidize emergency medical care for accidents and injuries. Even the most addled libertarian wants ambulances at car accidents. America does OK on this although with many funding hiccups and some price gouging too.

      The much harder question is whether government is responsible for self-contained diseases. If you have high blood pressure or diabetes, that does not give me high blood pressure. If every American with high blood pressure dies five years early, the nation and its economy would not suffer We were a prosperous country in the 1950’s when many cases of high blood pressure went untreated.

      This is too big of a question to solve in a blog post, but my own preference would be to focus Medicaid on being sure that a poor person can get in and out of a hospital without financial torment, and not less important, making sure that the hospital gets paid something for acting in this case like a public institution.

      I also want to be sure that expectant mothers and young children get all the care they need. Medicaid should surely be expanded to more of that group rather than just AFDC recipients.

      Covering the doctor visits of a 50 year old with high cholesterol is something that I myself would put at low priority. Thus my response to the Oregon study is that I think it is somewhat irrelevant to public health.

    • Although less statistical, if you will, my work interviewing subjects about how they access healthcare shows one glaring consistency.

      The first thing uninsured people tell me they are going to do after they get insurance is “get all the tests.” They want to be reassured they are “OK” after having foregone check-ups and screenings for years and sometimes decades.

      So the spike in use of services without more to show for them statistically is hardly surprising. Once people no longer have to “catch up” we could see a leveling off of use and more gains statistically because the initial rush to get a medical clean bill of health will be over.

    • I wish the focus had been more on whether the people’s daily lives were improved. Did they get chronic aches, pains, discomforts taken care of? Did their children attend more school, did they miss fewer days at work? I think the focus on long-term measures that are hard to budge even among the insured neglects the nagging health issues that sap a person’s energy and productivity. That is where I would have hoped to have seen an improvement.