The Oregon Health Insurance Experiment: A Touch of Clarity

In 2008, the state of Oregon expanded its Medicaid program via lottery (Oregon Health Study), and researchers released it preliminary findings this week. Published in The New England Journal of Medicine (NEJM), the findings suggest that the methodology used represented the first use of a randomized, controlled study design – the gold standard for medical evidence -to evaluate the impact of expanding insurance to otherwise uninsured individuals.
A few words about methodology of using randomized trials for the purpose of evaluating results and determining policy. Inferring the impact of health insurance from comparisons between the insured and uninsured is difficult because the insured and the uninsured may differ in many ways – income, employment, or initial health – that may themselves affect the outcomes being studied, a fact that is acknowledged by the authors. Yet the authors’ view that “random assignment of health insurance to some but not others avoids such confounding factors”, is misguided. Our aim should not be to eliminate the context from that which is being examined, i.e., socio-economic environment, from the use of medical insurance, but rather inspect access to and use of insurance schemes within that context. Thus, in order to fully evaluate the impact of such expansion, it is imperative to determine whether the state of Oregon made it possible for the now-insured to take full advantage of the insurance. By full advantage I am referring to sufficient access to physicians and clinics; the existence education program which informs newly diagnosed patients on the importance of compliance; the presence of programs that incorporate the importance of change in lifestyle and eating habits on health outcomes, as well as availability of tools to manage and coordinate care.
I am dumbfounded by the fact that the authors chose to formulate their one-line background in the NEJM as “the effects of expanding coverage are unclear.” Further scrutiny suggests that just in financial hardship alone the expansion of Medicaid virtually eliminated out-of-pocket catastrophic medical expenditures (expenditures that exceeded 30 percent of income) and reduced other measures of financial strain, such as reducing the probability of having to borrow money or skip paying other bills because of medical expenses by more than 50 percent. Furthermore, Medicaid increased the use of physician services, prescription drugs, and hospitalization by about 35 percent; the probability of having a usual place of care by 50 percent; increased the use of preventive services and screening, such as increasing the probability of having a cholesterol check by more than 50 percent and doubling the probability that women over 50 had a mammogram. Lastly, in terms of mental health, the expansion reduced observed rates of depression by 30 percent; increased the probability of being diagnosed with depression and increased self-reported mental health. Not to mention increased the probability of being diagnosed with diabetes a leading cause of mortality and morbidity in the US.
The one result that most critics and the authors (!) “hang their hat on” is the fact that Medicaid had no statistically significant effect on measured and diagnosis of, or medication for, blood pressure or cholesterol. To that I would say a few things: First, the study examined results only after two year post rollout – hardly sufficient time to examine outcomes. Second, both cholesterol and blood pressure medication are the hardest to comply with as not taking them does not make any patient feel worse – this is a known fact in the study of cardiovascular care. Third, taking medication without significant and meaningful change in life style hinder results in a meaningful way.
To sum, rather than champion the study as having “unclear” results, authors should have paraded the experiment as one, which has substantially increased the use of preventive care (which will exponentially decrease future use of health care), decreased current use of emergency rooms, and substantially decreased the probability of poor people being further impoverished as a result of crushing medical expenses. Now, what is so unclear about that?

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Categories: Law, Policy, and Government, Means of Reproduction

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