Wednesday, March 29, 2017

Douthat just sayin, on the ACA

It's Propaganda Wednesday for Monsignor Ross Douthat, Apostolic Nuncio to 42nd Street ("Is Obamacare a Lifesaver?"), out to let us know we shouldn't be too triumphant over the prospect of living with the Affordable Care Act "for the foreseeable future", as Ryan has said:

now that every G.O.P. policy person who ever championed a replacement plan is out wandering in sackcloth and ashes, wailing, “The liberals were right about my party, the liberals were right about my party,” beneath a harsh uncaring heaven … now, in these hours of right-wing self-abnegation, it’s worth raising once again the most counterintuitive and frequently scoffed-at point that conservatives have made about Obamacare:
It probably isn’t saving many lives.
Note how he stacks the argument in advance by calling it a "point" rather than "a basically unfounded assertion". And the weakness of restricting the issue to that of "saving many lives" (it doesn't mean anything if it improves the quality of life of millions? it doesn't matter if it only saves a relative few? how many lives would be worth the trouble?). And the hedge of "probably", which has no technical meaning here (how would you calculate the probability?) but is merely a way of saying, "Well, who knows?" Just sayin, as usual. But just sayin in italics, so we'll know it's serious all the same.

The evidence he has to offer being mostly old garbage from Megan McArdle, including the "probably" and the focus on mortality rates. Starting with a 2010 piece from The Atlantic where she explained that even though it might be true that, as an Urban Institute study claimed in 2008, that 20,000 Americans a year were dying for lack of health insurance, it also might not, because most uninsured people are poor, so they probably have bad habits, QED (How Megan is that?). Plus health care can kill you, remember Vioxx and Fen-Phen, to say nothing of iatrogenic infections.

Then there's the Massachusetts vs. Oregon canard. A study of the 2006 Massachusetts health care reform (falsely known as "Romney's") found that over the period from 2001 to 2010 the law decreased the mortality rate among 20- to 64-year-olds overall by 2.9% or 8.2 deaths per 100,000 (deaths amenable to medical care decreased by 4.5%) compared to a control group of similar counties outside the state. But an experimental study of poor people in the metropolitan Portland area who won a lottery giving then temporary Medicaid over a two-year period found that hardly anybody 19 to 64 ever dies in Oregon anyway, so there were no results on that, but participants did not have better scores for high blood pressure, elevated cholesterol, high glycated hemoglobin levels, or long-term cardiovascular risks, though they did have higher use of health care services, higher rates of diabetes detection and management, lower rates of depression, and reduced financial strain compared to those who lost the lottery. Therefore, according to Megan McArdle, the Massachusetts results are questionable (I discussed this idiocy when it came out three years ago).

Then something new and bizarre, a data analysis by blogger Spotted Toad suggesting with some extremely strong numbers that expanded Medicaid literally causes an increase in opiate overdoses, presumably because young people's increased access to healthcare is an increased access to OxyContin prescriptions compared to those in Red states that rejected the expansion. There are some problems with the explanation (young people's increased access to healthcare isn't through Medicaid as much as the ability to stay on their parents' plans up through 26 and the Marketplace private insurance policies; and prescription pills seem to be less responsible for the deaths than illegal opiates), but more important, this isn't a serious argument against the ACA: as Spotted Toad writes, and Ross doesn't quote,
This doesn’t “prove” that it was the Affordable Care Act that caused this jump upwards in overdose rates in counties in “blue” Medicaid expansion states. As I’ve said before, I don’t think it was purely the Medicaid expansion itself that did it- more the full-court press to enroll young people in these states, with the knock-on effect of a subset of young people realizing they could use their insurance for pills (whether to resell or to use themselves.)  Nor, needless to say, does this mean that the Affordable Care Act was a “bad idea”- it just means there are costs and benefits to the policy, and some of the biggest costs were those not scoped out in advance.
But this appears to me to be reasonably strong evidence that something went wrong, and also that, even if the majority of overdoses are now from heroin and fentanyl, prescriptions for opiates still need to be looked at very carefully.
It's the problem of overprescription, which really has to be dealt with through better regulation of medical practice, not less regulation, and which is magnified by the Medicaid expansion, not the Medicaid expansion itself.

But whatever is driving this trend, it’s a reminder that insurance coverage does not guarantee public health improvement.
Yes, Ross, we need more government as well. And keep in mind that the opioid overdose death rate on its own isn't a significant driver of early death rates anyway (of the Death by Despair issues, suicide especially and alcohol abuse, neither apparently caused by Medicaid, play numerically much more important roles).


And so is a new paper, just released through the National Bureau of Economic Research, that tries to look at the Affordable Care Act in full. Its authors find, as you would expect, a substantial increase in insurance coverage across the country. What they don’t find is a clear relationship between that expansion and, again, public health. The paper shows no change in unhealthy behaviors (in terms of obesity, drinking and smoking) under Obamacare, and no statistically significant improvement in self-reported health since the law went into effect. (There is some improvement for older Americans in Medicaid expansion states, but not for the population as a whole.)
That last bit is false: Ross is reading the results on self-assessed health incorrectly.
We do, however, find some evidence that the ACA improved self-assessed health among older non-elderly adults, particularly in expansion states. 
It's better for those older-but-not-elderly people all over, just more markedly where Medicaid expanded. Moreover, Douthat doesn't mention that there was no reason to predict a particular change in unhealthy behaviors, as the authors of the paper point out—
Insurance coverage could influence risky health behaviors – such as smoking, drinking, and overeating – in either direction (Cawley and Ruhm, 2012). On one hand, improved access to care could translate to improvements in health behaviors via information, accountability, or treatments such as smoking cessation drugs or weight loss programs. On the other hand, insurance can theoretically worsen health outcomes through ex ante moral hazard, as the reduction in financial risks associated with unhealthy behaviors incentivizes such behaviors. Moreover, income effects from gaining free or subsidized coverage could influence behaviors by enabling consumers to spend money they had budgeted for direct purchase of health care on alcohol, cigarettes, and junk food or, conversely, on healthy food and gym memberships (Simon et al., 2017).
That it hasn't had those adverse moral-hazard effects is good news for everybody, though bad news for conservative ideologues.

The NBER study doesn't mention, for a very good reason, the impact on measured health outcomes, physical metrics like those of the Oregon experiment or mortality rates as in Massachusetts. It also doesn't mention that ACA has had none of the adverse effects on the work and wages environment that were anticipated by the right—

—safety net hospitals benefited from having to provide significantly less unpaid care in Medicaid expansion states, people, especially cancer patients, have reported fewer financial worries thanks to the ACA, the Act has had a positive effect on job mobility for the fathers (but not especially mothers) of children with chronic health conditions, cost sharing for women has declined and their participation in preventive care has increased.

But we really don't know what the health care impact is yet, two years after implementation (which is still partial—the employer mandate hasn't yet extended to businesses with 50 to 100 employees), just as they didn't in Oregon after two years and did in Massachusetts after four. It probably is saving lives, based on the only relevant evidence (from Massachusetts; Douthat suggests that's not so relevant because Medicaid wasn't an important part of the Massachusetts reform as it is of ACA, as if to suggest that insurance may be OK but Medicaid may be downright lethal). But there's just no justification whatever for Douthat's claim. 

No comments:

Post a Comment