There’s an old public policy joke pointing out how sometimes issues that really aren’t debatable are portrayed as such in a media that strives to be evenhanded. It starts with a particularly dogmatic legislator declaring in committee that “the earth is flat” and who is then obviously contradicted by his peers. The headline on the story about the committee debate though? “Lawmakers Disagree on Shape of Earth.”
I often recall this joke when I see yet another attempt to argue that somehow a person having health coverage through a state Medicaid program results in no better or even worse health than someone who is uninsured. Because the debate in the last twenty states that still are refusing the federal money available to extend health coverage through Medicaid is becoming increasingly heated we are seeing these specious claims crop up yet again. Given this I thought I’d review the recent research confirming what you shouldn’t have to be a scientist with a PhD in epidemiology to know – having health coverage is better for a person’s health. And better health isn’t the only reason to get covered either. Health coverage plays a critical role in financial security for everyone whether they are rich, poor or somewhere in between. The only people I’ve ever met drowning in medical debt were those with pre-Affordable Care Act bare bones health “plans” and those without coverage at all.
Back in 2012 an article in the New England Journal of Medicine looked at this issue in states that had done expansions of Medicaid previous to the passage of the Affordable Care Act. The authors concluded: “State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.” This was followed in 2013 by another study in the New England Journal, this time in Oregon. Funding circumstances led Oregon to randomly offer expanded Medicaid coverage to a large group of people in the state in 2008 and not to another via lottery. By comparing these similarly situated groups researchers could compare the effects of expansion over two years. In this study researchers found that coverage did not have an effect on hypertension or high cholesterol levels – a finding seized on by the “Medicaid is bad” crowd. Conveniently overlooked by these Medicaid naysayers were the other conclusions of the study: Medicaid increased the diagnosis of diabetes and its treatment, significantly reduced clinical depression, increased the use of preventive health care and “nearly eliminated catastrophic out of pocket medical expenses.” And published just this month in the American Journal of Public Health was further analysis of the data in the Oregon Health Study showing that providing Medicaid coverage was a substantial taxpayer cost saver in Oregon – even if one only considers the savings from reducing the rates of clinical depression and doesn’t consider savings from the higher rates of preventive care or financial security. So, while there are some health areas where Medicaid had no effect there were plenty of other areas where it did. I guess for Medicaid critics, unless a health insurance plan meets the impossible standard of being 100% effective all the time, then it apparently isn’t any good – but all these studies do show improvements in health and well being.
Overall, health coverage -public or private coverage – is consistently seen to improve health. There are multiple studies. For example, a pre-Affordable Care Act study of 23 million hospitalized children in the United States concluded that mortality was lower for children hospitalized who were either covered by Medicaid or private insurance as compared with those who were uninsured. As a often-cited article looking across multiple countries in the health journal Lancet put it: “The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people.” And a recent Mathematica brief reviewing research on the topic found that “Insurance coverage is strongly related to better health outcomes for both children and adults when it makes health care affordable and helps consumers use care appropriately.
Medicaid critics like to ignore all this research and point to one study from the University of Virginia looking at surgical outcomes for Medicaid, privately insured and uninsured patients. One politician even claimed that this study meant that Medicaid patients were “97% more likely to die” than privately insured patients – a claim unsurprisingly rated as mostly false by fact checkers. Why? The Virginia study showed an association – that in some cases poorer, sicker people on Medicaid have a harder time after surgery than privately insured patients. This was not a causal link – that Medicaid coverage was the reason for this outcome instead of people on Medicaid just being poorer, sicker and getting to treatment later. In addition, people citing this study don’t like to cite its other finding: that “privately insured patients had higher pulmonary, urinary, gastrointestinal, systemic, and procedure-related complications than did uninsured patients” – a finding that apparently doesn’t yet have Medicaid critics rushing to jettison their own health coverage to “improve” their surgical outcomes. Indeed, in a recent interview the study’s own author refuted the claim that Medicaid was the cause of bad surgical outcomes: “So does that mean Medicaid is the culprit for the higher odds of patient deaths? Not at all, University of Virginia School of Medicine professor and cardiovascular surgeon Dr. Irving Kron (rhymes with “phone”) told us. Kron was one of the researchers for the study.”
Finally, even current vociferous critics of Medicaid expansion can’t help praising Medicaid’s benefits to patients – at least before Medicaid expansion became an issue. Back in 2011 one critic writing for The Heritage Foundation extolled the benefits of reforming the program, ironically in many of the ways currently being proposed for expansion. He wrote: “During its five years of operations, Florida’s Medicaid Reform Pilot has been a decided success. It has improved the health of enrolled patients, achieved high patient satisfaction, and kept cost increases below average, saving Florida up to $161 million annually.” Irony indeed.
What critics of Medicaid seize on is the fact that science as done in these studies and presented in peer-reviewed research articles is almost never going to produce absolute, complete certainty about any topic. But that doesn’t mean the debate on some topics isn’t essentially over. Even though everyone can’t get in a spaceship and zip up into orbit to confirm the earth is actually round, we all (at least most of us) agree that contrary to our senses the earth is indeed round. In the same way, the extensive science is comprehensive and consistent – having health coverage is good for a person’s health and financial well-being. There is always room for improvement in how we deliver health coverage but being able to see a doctor when needed without going bankrupt is indisputably a good thing.