A recent study published in the New England Journal of Medicine* on the Oregon Medicaid program has elicited reactions fitting for that twilight zone at the intersection of academic research and politics. Kaiser Health News characterized the paper as serving a “Rorschach test for how partisans and health policy wonks view the health care law”**
Oregon did a limited expansion of Medicaid in 2008 by offering coverage to individuals who met income and other eligibility requirements and were winners of a lottery. That meant that about 30,000 adults were newly enrolled in the Medicaid program out of 90,000 eligible. The state thus created a classic experiment with a control group and a treatment group.
The study found significant differences in the two group’s access and utilization of health care, a substantial improvement in mental health outcomes for the Medicaid covered population, a significant reduction in financial strain on covered families and significant increase in self-reported health. It did not however, find significant improvements in the three objective measures of physical health outcomes. The paper states: “Medicaid coverage had no significant effect on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. It increased the probability of a diagnosis of diabetes and the use of medication for diabetes, but it had no significant effect on the prevalence of measured glycated hemoglobin levels of 6.5% or higher.” From that result a number of headlines were created that stated: “Medicaid Expansion May Not Improve Health of Poor in U.S.”***
The truth is the study didn’t examine the effects of insurance coverage on health. It measured the effects of coverage on families financial strain, utilization of health care services, and measures of the process of care for three specific conditions. It found positive effects for financial strain, health care utilization, an improvement in those with depression, no effect for hypertension or high cholesterol, and an increase in the diagnosis and care for those with diabetes. The paper states: “although we did not find a significant change in glycated hemoglobin levels, the point estimate of the decrease we observed is consistent with that which would be expected on the basis of our estimated increase in the use of medication for diabetes”. In other words, more diabetics were diagnosed and given access to medications to control their illness when they had insurance. There are many studies that document the health and cost effects of diagnosing and treating diabetes. The study is in fact is consistent with a large body of research that documents the benefits of access to health insurance on individual health.
The real non-sequitur is the discussion of this study is failing to understand the economic consequences of health insurance coverage. If health insurance has no effect on health why are millions of American’s buying it? For most families health insurance provides access to health care they could not afford without coverage. If that care is ineffective then why get access. The truth is that while health care may be inefficiently provided the benefits of that care are well documented and obvious to most.
It could be argued that the Medicaid program does not increase access to care sufficiently to generate better outcomes. This study, and many others, finds that expanding Medicaid generates significant increases in the use of health care services. Studies of past Medicaid expansions for pregnant women found significant improvements in birth outcomes where the woman was enrolled for the entire pregnancy and received care at facilities that treated a higher percentage of low income patients. Access helps; access to appropriate care help more.
In the case of this study, even while only documenting a small portion of health effects the economic benefits from increased access are clear. Increased access to care reduces the prevalence of depression, and identifies and provides treatment for diabetics. With treatment these individuals are more productive. Without access to treatment for both of these conditions individuals are more likely to use emergency rooms and require inpatient care. Without Medicaid the costs of that more expensive treatment is born by local taxpayers, and other health care consumers.
In short, the study is consistent with other research and with common sense: expanding Medicaid increases the health and reduces the financial burden of families in and out of the Medicaid program.
*“The Oregon Experiment — Effects Of Medicaid On Clinical Outcomes” Katherine Baicker, Ph.D., Sarah L. Taubman, Sc.D., Heidi L. Allen, Ph.D., Mira Bernstein, Ph.D., Jonathan H. Gruber, Ph.D., Joseph P. Newhouse, Ph.D., Eric C. Schneider, M.D., Bill J. Wright, Ph.D., Alan M. Zaslavsky, Ph.D., and Amy N. Finkelstein, Ph.D. for the Oregon Health Study Group N Engl J Med 2013; 368:1713-1722May 2, 2013DOI: 10.1056/NEJMsa1212321