Expanding Medicaid Coverage Is Beneficial (Ignore Those Conservative Bloggers Arguing Otherwise)

A study in The New England Journal of Medicine comparing people with and without Medicaid in Oregon provides an excellent example of how the right-wing blogs can take data and cherry pick the information which supports their views while ignoring the full set of information. The study does not provide evidence against expanding Medicaid through the Affordable Care Act, despite their spin. This is a topic which I wish I had more time to devote to tonight, but only have the time for some brief remarks.

The study shows that with some measures of medical care those receiving Medicaid coverage did better than similar adults who did not receive Medicaid coverage in Oregon’s lottery but there was not a large enough sample for the differences to be statistically significant. The most significant differences were reduced rates of depression and financial strain:

In particular, catastrophic expenditures, defined as out-of-pocket medical expenses exceeding 30% of income, were nearly eliminated.

Reducing financial strain is a rather significant benefit of having medical coverage. That’s also a key reason why so many people are concerned about receiving health care benefits from their employer and having Medicare coverage after they retire.

Showing improvements in measures of chronic diseases in a two year study, but not enough to be statistically significant yet, really comes as no surprise. It takes time to see major improvements in diabetes care, and the improvements shown in this study are a real start.

The results could be better. When I receive new diabetic patients who are poorly controlled I will see them every two weeks, and have them in for blood sugars in the time between these appointments. A new diabetic appointment will be well over an hour, and not uncommonly two hours. The glycated hemoglobin levels used in the study provide an average measure of blood sugar over the past 3 months. (It is a test of the effects of elevated blood sugars on red blood cells and provides an average based upon the life span of red blood cells). With intensive treatment of uncontrolled diabetics it still takes several months to see a statistically significant change.

I generally do see greater drops in glycosylated hemoglobin over the first year of treatment than this study is showing in two years. Of course this is not with Medicaid patients. No doctor could afford to do this with what Medicaid pays. The study shows that a poorly funded program provides some benefits. Giving the same people coverage at the level of private insurance, or at least Medicare, would probably result in even better outcomes. This study is not evidence that providing Medicaid doesn’t provide benefits, but it could be argued that to provide better results we should be putting even more money into health care benefits. I would also expect to see more impressive  improvement over a longer period of time.

I am surprised that they used HDL level as a measurement in the study as, while improving it will decrease the risk of heart disease, it is very difficult to change HDL levels regardless of medical intervention. Having Medicaid coverage would not be expected to affect this.

Two years is not long enough to meaningfully evaluate changes on chronic diseases. An evaluation of treatment for acute problems would be more meaningful over this time period. Kevin Drum’s impressions on this are correct:

The study suffers from the usual problem of measuring “outcomes,” and suffers especially because it measured only a very limited set of outcomes (primarily chronic conditions like blood pressure, cholesterol, and diabetes). This has long been one of my pet peeves. The problem is that there are lots of things that improve your quality of life but don’t show up as an improvement in either mortality rates or glycated hemoglobin levels. If I have an infection, for example, a course of antibiotics is a godsend. More than likely, though, the infection would have gone away eventually on its own. Does that mean the medication was useless? Of course not. Ditto for arthritis meds, a better pair of glasses, a new hip, a root canal, or fixing a broken ankle.

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.