Among all the criticisms of President Obama’s health care reform law, the most salient may be that the Affordable Care Act focuses on access to insurance at the expense of cost and quality care. A new set of results from a study on Oregon’s Medicaid program supports this critique and offers a window into the broader shortcomings of the U.S. health care system.
The results, published this week in the New England Journal of Medicine, found that in a randomized controlled trial, the health of Oregonians on Medicaid did not differ significantly from a control group left off the rolls of the public insurance program. Researchers looked at the health of some 12,000 people, measuring their cholesterol and blood-sugar levels, among other factors. The results also indicated that Medicaid enrollees were less prone to depression, less likely to incur catastrophic out-of-pocket health expenses and much more frequent users of health care services. (Study participants were gathered from a group of Oregon residents eligible for Medicaid and put on a waiting list for the program. Those able to enroll in Medicaid were chosen by lottery and compared against those left on the waiting list.)
These findings can tell us many things about American health care. Here are a few:
Preventive care isn’t all it’s cracked up to be. The Oregon study found that people on Medicaid got more preventive care — including mammograms, flu shots and Pap smears — than those in the uninsured control group. While it might seem logical that heading off and identifying potential health problems early through screening tests and doctor visits will lead to faster, cheaper treatment, the truth is much more complicated. Prevention as a population-based health strategy saves money only if the savings generated by preventing or catching health problems early in some people outweighs the cost of all the doctor visits and screening tests performed on people who are well and don’t need treatment. In addition, some screening tests — particularly those intended to catch certain cancers early — lead to lots of unnecessary harm and false positive tests.
We need more quality control in medicine. The Affordable Care Act includes programs and funding to add more quality control to health care, but this priority is eclipsed by the law’s emphasis on expanding health-insurance coverage, largely through Medicaid. The fact that payments to doctors and hospitals don’t depend on health outcomes in most cases is an enormous problem. As the Oregon results showed, Medicaid enrollees got more care, in doctor’s offices in particular, when they had insurance but didn’t necessarily have better health. This is partly because their doctors got their Medicaid payments regardless of whether the care they provided was effective.
This leads directly to another insight we can glean from the Oregon results: patients need to be more involved in managing their health. Chronic conditions like hypertension and diabetes have a lot to do with weight, diet and adherence to medication regimens, which patients can control. Without a patient’s commitment to carefully manage these factors, the best and most available doctor on the planet won’t make much difference in the overall health of many people. It’s hard to think of a way that the government can address this. Revoking insurance for patients who don’t take good of themselves would never fly, although the Affordable Care Act does allow insurers to charge smokers higher premiums and some corporations offer cash payments or breaks on insurance premiums if workers participate in wellness programs.
Medicaid is not enough. The Medicaid and control groups in the Oregon study are statistically identical in terms of race, age and gender. In addition, everyone in the study was eligible for Medicaid, meaning they were all poor. But as policy experts know, poor people have health risk factors that don’t include access to insurance and doctors. Getting on the Medicaid rolls doesn’t automatically eliminate factors like lack of education, lack of access to healthy food and household financial strain that can impact health and health management.
Insurance is about health, but it’s also about money. A major value of comprehensive health insurance is that it protects people from financial ruin if they have a horrible health emergency or an expensive long-term condition that requires treatment. A homeowner living near a river doesn’t buy flood insurance to prevent floods or protect his home if a flood occurs. He buys flood insurance so that if his house is destroyed, he will be able to recover financially. This too is a major purpose of health insurance. The latest results from Oregon showed that being on Medicaid “nearly eliminated catastrophic out-of-pocket medical expenditures.” This matters and may be part of the reason earlier results from the ongoing Oregon study indicated that those on Medicaid were happier.