OP-ED

Evidence That Health Does Not Equal Healthcare? Early Results From the Oregon Experiment Are In

The most important study in American health policy in decades, the Oregon Health Insurance Experiment, published two-year results Wednesday in the New England Journal of Medicine. If you’re reading up on the topic, get ready for bombastic claims and scorching heat as opposed to illuminating light. The quick read leads to an easy Drudge headline – “MEDICAID DOESN’T MAKE PEOPLE HEALTHIER: OBAMACARE WILL FAIL!” – but a fuller reading of the evidence provides a more optimistic, and honest, take.

In 2008, Oregon had 90,000 individuals who wanted to enroll in its Medicaid program, but the funding to enroll only a fraction. So it decided to use the opportunity to create an unparalleled experiment: the first Randomized Controlled Trial (RCT) – the gold standard research methodology that is able to isolate the causal effect of an intervention – in Medicaid history. It endeavored to show nothing less than the actual, causal effect that Medicaid has on its population, a first in the field.

This study, in other words, is a big, big deal.

Two years of data are in, and the results are mixed. First up, the disappointing: 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.”

The prevalence of high blood pressure and high cholesterol levels weren’t significantly affected by Medicaid coverage, nor was the use of medication to treat them. Even more surprising, increased diagnosis and treatment of diabetes didn’t affect how well enrollees were managing their disease. That is quite surprising, and butts up against our intuition, which holds that diagnosis and treatment of a disease should lead to better control of that disease.

But these figures should be taken in context: because the sample sizes for the above conditions were relatively small, statistically significant outcomes look more disappointing than actual outcomes. For example, the prevalence of hypertension decreased by 7.16% in the Medicaid covered population – a “[change] that would be considered clinically significant.” A larger study population could have shown this finding to be statistically significant, too.

In addition, the study unearthed a number of encouraging findings. Compared to the control population, Medicaid enrollees were 30% less likely to self-report depression; more likely to utilize health care services, including using more prescription drugs, making more visits to the clinic, and having more cholesterol-level screenings done (which increased by almost 50%); and more likely to report higher levels of self-judged health.

(chart from The Oregon Health Insurance Experiment website, via Austin Frakt)

Just as important, being enrolled in Medicaid had a substantial effect on catastrophic medical expenses and medical financial hardship. According to the study, “Catastrophic expenditures, defined as out-of-pocket medical expenses exceeding 30% of income, were nearly eliminated” (emphasis mine). The percent of people who borrowed money to pay bills or skipped payment fell precipitously, by 58%, and the percent of people with any medical debt dropped by 23%. In other words, health insurance is doing what it is supposed to do – protect the consumer from out-of-control, unanticipated medical bills.

That’s a pretty compelling case for Medicaid expansion: less depression, more access to physicians and pharmaceuticals, and a near-elimination of catastrophic, life-changing medical expenditures.

And, as Annie Lowery astutely points out, there’s a lot that this study doesn’t tell us. With only two years of data in, it’s difficult to say what effect Medicaid coverage will have in ten years, or twenty; one could argue that many of the health measures will take more than two years to stabilize, or that the reduced financial strain may lead to long-term reductions in stress levels, which could have an effect on hypertension and heart disease.

Where all of this leaves you probably depends on where you stood before. If you believed Medicaid doesn’t make beneficiaries better off, your evidence for that can (arguably) be found in this study; if you believed that Medicaid leaves beneficiaries better off, you can make that case, too.

But whatever you’re inclined to believe, the truth seems to be somewhere in the middle. Health insurance can only do so much; as Aaron Carroll and Austin Frakt point out at the Incidental Economist, it’s “necessary, but not sufficient to improve health” – one piece of a much-larger puzzle. If nothing else, this study should illuminate the need for better health coverage, not just more; merely having the insurance isn’t enough if it’s not paired with the right type of intervention. Health policy researchers, policy wonks, innovators, and practitioners should work together to create a product /service that takes coverage a step further and, for instance, leads to sustained and marked improvements in diabetes control.

For now, we’re stuck with a bit of ambiguity, along with brash headlines, condemnations of government intervention, and pundits discussing What This Means for Obamacare. This argument won’t be settled today, tomorrow, or next week, so buckle in for the ride.

Mike Miesen is a healthcare consultant and recent graduate of the University of Wisconsin-Madison. He is currently on loan to the Ugandan Ministry of Health (via NGO), leading a project to reduce maternal mortality. You can follow him on Twitter @MikeMiesen.

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  11. Health insurance helps but I have had Medicare & Medicaid since my surgeon messed up my back surgery and damaged a nerve in my leg which caused my now social security disability thus Medicaid because I was unable to return to work because of the damage he did in surgery. My surgery was to have been 4 hours but became 8 and massive complications that no one reported in medical records but for some reason something he put in those records that were only sent to government and not anyone else I received disabilty . He probaly knew he messed up the surgery but did not want to be liable for the error and it was absolutely caused by surgery that every doctor afterward that I saw stated the surgery caused the disability and my damaged leg nerve but they could not repair it now. Too many malpractice lawsuits are a myth. Immediately after the surgery I was also extremely tired and falling asleep during the day. I did not have this problem before the surgery. It got worse and worse and several years later I started having morning headaches and wasn’t able to sleep longer than 60-120 minutes. My body was shutting down because I wasn’t getting any sleep. I stopped dreaming as well. because it depends on the competency of the doctors a patient sees. Medicaid doctors I have seen cannot even write correct medical records I found when I requested mine after I learned 10 years too late I now had severe obstructive sleep apnea and not a single Medicaid doctor & Medicare knew the classic signs I had been reporting for 10 years of obstructive sleep apnea. I had to ask for the sleep test because not a single doctor suggested possible obstructive sleep apnea. a nurse ordered the test for me. I received the test results but my doctor never seemed to find them no matter how many times they were sent to her because they were never in my file when I returned. I could not wait until she found them and handed them to her. She never explained any of the test results, did not order the repeat titration study until I filed a letter of complaint. She did not read the report and ordered the wrong Rx and had to change the CPAP to Bi-pap and when she did not refer to a specialist or consult with an ENT or looked at the data card from the machine I knew I had to leave that family clinic that had been my primary care provider for 10 years to find my own doctors because that clinic did not care whether I got better or what was causing my inability to stay awake during the day and should never drive because I was falling asleep in minutes. Then I learn a year later from my second sleep specialist that first sleep report titration had not been read correctly because it showed that NO PRESSURE WAS FOUND that would allow any bi-pap to work not even CPAP because of correct 2nd test results. When I got my records from a year of treatment from the first sleep specialist she had massive errors in them and she also had reseased these incorrect medical records back to the primary care doctor who I discussed with her had not referred me or ordered any tests and I had fired this doctor for incompetence. she agreed that my records were only temporary until I verified they were correct because of the gross negligence of my past primary care doctors. I discovered when I saw my records from my past medical clinic my doctor in 2005 stated I should have a sleep test but it wasn’t ever ordered and I was never told about it because she suspected high probability of obstructive sleep apnea. My new primary care doctor in 2009 had not looked at any of my medical file because she also never ordered the test as I had asked . I have had to do all my own research to diagnose myself because doctors cannot hear what I have been telling them and could not write the symptoms I was telling them. Medicine is only as good as the doctors who can give the correct diagnosis and who actually can hear what the patient is telling them or to ask the right questions. I gave my doctor everything she needed to have her start trying to diagnose my severre illness but she did not write any of what I was telling to her in my medical records. The caliber of doctors who are treating Medicaid patients is hightly suspect and this is what we are left with to have to do our own research all over the internet to read medical journals that have been published. My sleep doctor also violated Medicare rules by continuing Bi-pap when I repeatedly informed her no improvement getting worse. she should have run another sleep test but she refused so I left her care and got the second doctor who informed me she was incorrect in writing the Bi-pap Rx because a CPAP did not help either because of my nose and throat anatomy that I discovered after the ENT consult that I had to get on my own. I now voice record appointments with doctors and send confirmation letters due to totall incompetence. I have also had 3 Bi-pap machines fail within 6 months as well . Again waiting to get another consult with UCSF because my east bay doctors haven’t done anything about no improvement of severe obstructive sleep apnea.

  12. Agree, a very important study, given how rarely large- scale policy changes are implemented using randomization.

    Fact-check: this post mis-states what the investigators found re elevated BP. The actual effect reported is 1.33% reduction among the group who obtained Medicaid coverage vs. the control group. This was not statistically signficant. The confidence interval, which is a statistical construct, ranges from -7.16 to + 4.49. You cannot make any inferences about what might or might not be “clinically significant” from this study. Given this confidence interval, you could just as easily argue that Medicaid coverage worsens BP control!

  13. Very interesting. I think this study shows that interacting with the health care system does NOT make you healthier unless you WANT to be healthier. Just because more people see a doctor does not mean more people take their medication or do what the doctor says. In fact, one could argue that if you don’t see the doctor you don’t get diagnosed and thus you can’t measure the health of people that don’t provide data points by going to the doctor. Those people might be the healthiest of all!

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