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A major new Medicaid study has become a hot political story in the way only a story about improving the lives of low-income people could: Republicans are using it to argue that expanding health care is a bad thing. The study comes from the New England Journal of Medicine (subscription only), reporting on health outcomes from a two-year experiment in Oregon. A few years ago, the state had enough funding to increase Medicaid eligibility to 10,000 more residents, and they held a lottery to pick those lucky souls. This set up a pretty perfect study opportunity for researchers: compare the health status of those who applied and received Medicaid coverage against those who applied and didn't. The part the Right is seizing on is this:
This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.
Because in two years Medicaid coverage didn't show significant improvements in the measured outcomes—"blood-pressure, cholesterol, and glycated hemoglobin levels"—those on the Right arguing against Medicaid expansion in Republican states are crowing that they were right all along, that Medicaid coverage doesn't do any good and thus leaving people uninsured makes more sense than extending coverage. Which, as Jon Cohn argues, ignores most of the real lessons of the first two years of this experiment.
The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses. [...]

The other big finding was that people on Medicaid ended up with significantly better mental health: The rate of depression among Medicaid beneficiaries was 30 percent lower than the rate of depression among people who remained uninsured. That’s not just good health policy. That’s good fiscal policy, given the enormous costs that mental health problems impose on society—by reducing productivity, increasing the incidence of violence and self-destructive behavior, and so on.

There are any number of plausible explanations for why the study didn't find significant physical health improvement: the relatively short study period for significant health effects to occur; the relatively small sample size; the number of people within that sample who had issues with blood pressure or cholesterol or blood sugar to be improved upon. The study authors acknowledge that: "Nonetheless, our 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 most prevalent condition—depression—did improve and improved dramatically, which is not only a good thing but a thing really worthy of spending federal dollars on. But here's what else the study didn't find: worse health outcomes. Expanding Medicaid to more people absolutely doesn't hurt public health. Extending the security of having access to affordable health care has absolutely improved the mental health and the financial security of the people who received it.

That's the point of health insurance: You get it for the peace of mind of knowing that catastrophic illness won't ruin you physically and financially. That shouldn't be reserved just for people lucky enough to a) have job-related health benefits, b) have enough money to buy their own insurance.

Originally posted to Joan McCarter on Thu May 02, 2013 at 12:43 PM PDT.

Also republished by Daily Kos.

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Comment Preferences

  •  Contact info for NPR would be good; their hatchet- (3+ / 0-)

    job yesterday is an example of one-sided reporting:

    •  Meanwhile (2+ / 0-)
      Recommended by:
      indycam, anonymous volanakis

      Those of you who know how to read can read the actual story can recognize that they largely reported the same thing as this diary.  Yep, it's all in there

      Touch all that arises with a spirit of compassion

      by Mindful Nature on Thu May 02, 2013 at 05:56:13 PM PDT

      [ Parent ]

      •  only if you know what "statistically significant" (0+ / 0-)

        means, when used for a small sample size.

        The NPR article is  technically accurate, but misleading for most people.

        •  Small but not (0+ / 0-)

          Infinitesimal.  NPR reported it accurately.  If there is a large effect even a modest sample should detect it. Of course these measures are that sensitive and change slowly. However, "technically accurate" is accurate.  Changing the results to suit you political preferences is not accurate

          Touch all that arises with a spirit of compassion

          by Mindful Nature on Thu May 02, 2013 at 06:24:43 PM PDT

          [ Parent ]

          •  what's the comparison? the baseline result? (0+ / 0-)

            In other words, distinguishing "treatment vs non-treatment" and "Medicaid vs private insurance." The article conflates those two questions, making it appear that this result is specific to Medicaid, not to medicine as a whole.

            Two possible situations (exaggerated for clarity):

            1) Private insurance is massively effective, while Medicaid is insignificant.

            2) Neither private insurance nor Medicaid produce significant improvements on the measured outcome.

            Those are two very different and important results, but the article doesn't suggest #2 is even a possibility.

            In fact, the final section with the AEI hack spins the result as #1.

            So, yes, I'd say it's deceptive.

            •  actually (0+ / 0-)

              private insurance doesn't come into it.  It is only the need medicaid and get it, or need medicaid and get it.  

              so, it seems your objection is that the story quoted someone who is critical of medicaid?  

              Touch all that arises with a spirit of compassion

              by Mindful Nature on Thu May 02, 2013 at 07:06:46 PM PDT

              [ Parent ]

  •  The solution we need is obvious (2+ / 0-)

    pass a law banning studies on the effectiveness of federal aid programs.

  •  Let's take a "too small" sample of gun owners... (0+ / 0-)

    and conclude that the availability of guns has nothing to do with gun accidents or violent crime, because the number of people who got shot or robbed was too small to make any statistical conclusiions.

  •  Wait I thought this study was done by (1+ / 0-)
    Recommended by:

    Corporate shills paid by the Koch brothers!  There a reckisted diary that says so!

    Touch all that arises with a spirit of compassion

    by Mindful Nature on Thu May 02, 2013 at 05:55:03 PM PDT

    •  Funny isn't it . (1+ / 0-)
      Recommended by:
      Mindful Nature

      I guess the kochity brothers are now paying the corporate shill Daily Kos front pagers . Its the only explanation !

      Drop the name-calling MB 2/4/11 + Please try to use ratings properly! Kos 9/9/11 + Trusted Users have a responsibility to police the general tenor... Hunter 5/26/06

      by indycam on Thu May 02, 2013 at 06:08:17 PM PDT

      [ Parent ]

    •  So what? (1+ / 0-)
      Recommended by:
      Mindful Nature

      Data is data, no matter who does the study.   And this was a type of study that merely gathered data that was already collected anyway, and sought to draw conclusions from it.  You could take the exact same data and do your own 'study' and draw your own conclusions.

      People who actually understand healthcare wouldn't have actually expected medicaid to particularly affect any of those particular 'measures of health' (blood pressure, cholesterol, blood sugar) , and would also know that those listed measures tell you nothing about the usefulness about having health insurance, whether private or public.

      So conclusions like 'Medicaid isn't useful' are corporate shill type conclusions drawn from the data.

      •  that is all true (0+ / 0-)

        but the diary today suggested that both the results and the reporting of those results were paid for by Koch and were done by corporate shills.  The notion that conservatives distort the findings of scientific studies to defend nasty corporations is filed in the "water is wet" files I should think

        Touch all that arises with a spirit of compassion

        by Mindful Nature on Thu May 02, 2013 at 08:59:03 PM PDT

        [ Parent ]

  •  REC'd. Cohn is a must read on this. nt (0+ / 0-)
  •  Recent Medicaid, ER studies make stronger case (5+ / 0-)

    Ultimately, as Ezra Klein, Kevin Drum, Aaron Carroll and Austin Frakt all conclude, the limited sample size, short-time frame and narrow measures of "health outcomes" make conclusions about the efficacy of Medicaid difficult to reach. But combined with other recent research, there is little question that Medicaid expansion will make the financial prospects and quality of life significantly better for the previously uninsured. As for the legion of Republican politicians instead insisting "no one goes without health care in America" because "you just go the emergency room," studies documenting the rapid disappearance of ER's and trauma centers show that GOP talking point is just a cruel joke.

    For the details, see:
    "Medicaid, ER studies make strong case for Obamacare."

  •  When was the last time someone in Canada (5+ / 0-)

    needed to win a lottery in order to get health care?

    How come mass shooters are never charged with using a weapon of mass destruction?

    by jazzmaniac on Thu May 02, 2013 at 06:07:16 PM PDT

    •  Low income Canadians report poorer health than (0+ / 0-)

      rich Canadians.

      -    Only 47% of Canadians in the lowest income bracket rate their health as very good or excellent, compared with 73% of Canadians in the highest income group.
       -   Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of residence.
       -  At each rung up the income ladder, Canadians have less sickness, longer life expectancies and improved health.
      -   Studies suggest that the distribution of income in a given society may be a more important determinant of health than the total amount of income earned by society members. Large gaps in income distribution lead to increases in social problems and poorer health among the population as a whole.
      If health care is free and delivered to all Canadians regardless of economic situation, why are the poor sicker?
      Considerable research indicates that the degree of control people have over life circumstances, especially stressful situations, and their discretion to act are the key influences. Higher income and status generally results in more control and discretion. And the biological pathways for how this could happen are becoming better understood. A number of recent studies show that limited options and poor coping skills for dealing with stress increase vulnerability to a range of diseases through pathways that involve the immune and hormonal systems.
      By removing the financial burden of health care and by showing improvements in depression, Oregon is improving the lives of its "lottery winners" in important ways, even given the short timeframe of the study.
      •  Missing the point (1+ / 0-)
        Recommended by:

        The point isn't that people with health care are healthier than people without it.
        The point is that people with health care can get treatment when they get sick.
        We Canadians get just as ill, just as often as Americans do -- and poorer Canadians get sicker because they can't eat as well or get dental care.
        But all Canadians can see a doctor or go to a hospital when we need to, we don't have to go broke trying to pay for health care, or try to self-manage health conditions and do without longer-term treatments.

        Do not go gentle into that good night. Blog, blog against the dying of the light. CathiefromCanada

        by CathiefromCanada on Thu May 02, 2013 at 11:03:57 PM PDT

        [ Parent ]

  •  lots of people with good insurance can't improve (4+ / 0-)

    their sugar numbers really is difficult. it 's a disease after all....same is true for BP and cholesterol. therefore, using GOP logic, privatehealth insuramce doesn't work.

    •  In addition (0+ / 0-)

      I wouldn't be at all surprised if the lower income cohort of people who have these types of health issues (BP, diabetes, depression, cholestorol) are probably sicker and have been sicker for longer than their higher income fellow citizens -- and therefore it may take longer to see measureable improvements once they have insurance and regular access to care without going into bankruptcy. Which makes it all the more impressive that the dramatic improvement in depression rates was measured -- this is encouraging and hopefully this group's other health problems will improve over time too.

      Being poor is stressful and depressing. Aleviating just a bit of that stress clearly has major benefits -- not just to the individual but to society. Which of course we know, but it's nice to see it demonstrated, even if the study had some flaws.

      "The country we carry in our hearts is waiting." ~ Bruce Springsteen

      by abs0628 on Fri May 03, 2013 at 08:06:47 AM PDT

      [ Parent ]

  •  Auto insurance doesn't stop auto accidents (2+ / 0-)
    Recommended by:
    FindingMyVoice, berrieh

    but most folks would rather have it than not.

  •  I know why! (4+ / 0-)
    Recommended by:
    ferg, YuccaPete, antirove, DSPS owl

    30 plus years teaching people about their cardiac risk factors teaches me something for gosh sakes, and that is that changing those "hard" end points takes time!  Two years is a very short time horizon to look at those sorts of issues.  One of the biggest problems in the American system, which the ACA does very little to fix, is that people change insurers several times in their lives, which means that insurers have little incentive to invest in preventive care.  Preventive care is a huge financial winner - not to mention a human winner - but the benefits take time to show up.  In our fragmented system, if one payer invests in prevention, by the time the benefits show up, the patient will likely be covered by someone else.  Single Payer is as always, the only answer.

    "Wouldn't you rather vote for what you want and not get it than vote for what you don't want - and get it?" Eugene Debs. "Le courage, c'est de chercher la verite et de la dire" Jean Jaures

    by Chico David RN on Thu May 02, 2013 at 06:20:02 PM PDT

  •  I would be willing to bet if a longer (0+ / 0-)

    and larger sample had been used, the study would have found that people with diabetes, or early signs of diabetes, the effects of obesity and those with high cholesterol would have been diagnosed and steps to reduce the effects of those conditions would have shown marked improvement.

    As it was, the study results published were both incomplete and preliminary.  It should have been at least a five year study and should have included many more subjects.

    "In this world of sin and sorrow there is always something to be thankful for; as for me, I rejoice that I am not a Republican." - H. L. Mencken

    by SueDe on Thu May 02, 2013 at 06:21:43 PM PDT

  •  This baffles me... (4+ / 0-)

    I don't even get the premise... Why would healthcare necessarily improve physical health in areas over 2 years or, in many cases at all. Having healthcare doesn't prevent you from getting ill or having high blood pressure or anything... It just allows you to cope when you do. Hence the improved mental health.

    Is that why insurance companies act shocked and appalled when thy actually have to pay for services? Are people on the right under the impression healthcare somehow prevents disease?

  •  Erm.... (3+ / 0-)
    Because in two years Medicaid coverage didn't show significant improvements in the measured outcomes—"blood-pressure, cholesterol, and glycolated hemoglobin levels"
    Those are all chronic (ie, ongoing) conditions.  Most healthcare in the country is aimed at treating acute problems, or simply artificially controlling chronic conditions without actually improving them.  When you take lopressor, for instance, you're not actually improving your blood pressure, merely artificially lowering it during the time in which the drug is active in your system.  Even though you haven't 'fixed' blood pressure by doing so, there are still significant health benefits to your body by keeping your blood pressure lower, even artificially, such as reducing the strain on kidneys.

    Anyone who thought it through would be hard pressed to seriously expect medicaid, medicare, or any other insurance program that is mostly simply used to pay for acute healthcare issues to significantly alter chronic conditions.  It's just not what they do.  If you want to lower blood pressure, cholesterol, and serum blood sugar, you need to focus on primary care issues like exercise and diet.

  •  haven't Republicans (2+ / 0-)
    Recommended by:
    Square Knot, DSPS owl

    been saying that we needn't look to pass gun safety regulations because mental health is the real culprit, so they'd rather deal with mental health than guns.  Now this study show 30% reductions in depression, which is a mental health issue, and they're saying it's worthless?  Do these people not have any internal irony detectors?  Do they have no sense of shame?  Do they have any humanity whatsoever?

  •  When people know that they can see a doc (1+ / 0-)
    Recommended by:
    DSPS owl

    they can afford (and their kids too) you have already relieved stress which is a proven killer. However stress takes time to affect health but improvements in mental health would not take as long to see.

  •  Probably some degree of flawed study design (0+ / 0-)

    I reviewed only the abstract, and do not have access to the full article.  I doubt there would be much measurable change only 2 years after the lottery, and am curious how rapidly lottery winners were actually able to access Medicaid care, and also wonder what percentage of lottery winners actually did access Medicaid care. The measured conditions of HBP, diabetes, and elevated cholesterol all tend to be relatively "silent" compared to many more acute diseases, and I understand that patient compliance can be marginal in these diseases.

    The study raises more questions than it permits conclusions. I'd be curious if any statistically-trained bloggers could review the full study and parse out any flaws or biases.

  •  I may not be the most impartial reviewer... (1+ / 0-)
    Recommended by:
    DSPS owl

    ...But I am one of the study's authors.  I'm happy to answer questions if you like.

    Just to be clear, the full study is far from an indictment of Medicaid.  We actually found all sorts of important impacts of Medicaid -- financial protection, access to care,  more preventive care, and dramatically reduced depression.  People were also more likely to have their diabetes detected and treated.  These are all important things.

    We looked at a few specific clinical indicators of physical health and did not find differences.  We did not rule out that those differences might appear over a longer time period.  We chose those because they were ambulatory care sensitive conditions that earlier studies had suggested might be amenable to improved access in the time frame we had for the study.  

    I'll do my best to answer questions if you have any.  End of a long day, but I may still have a little left in me.  

    Soon we shall invent a method of being born from an idea. But enough, I shall write no more from the underground... --Fyodor Dostoevsky

    by Last Call on Thu May 02, 2013 at 08:52:37 PM PDT

  •  Oh yeah, funny how feeling better physically makes (0+ / 0-)

    you less likely to feel depressed.  And amazing how being able to go to a doctor and get things taken care of makes you feel a whole lot better.

    I'm sorry, I can't say here the words I want to say about the people who did this study.

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