Medicaid Study: May not make them healthier

[Magox]

Interesting study that I read about today in the Daily Beast.

 

Study: Giving People Government Health Insurance May Not Make them Any Healthier

 

 

 

Bombshell news out of Oregon today: a large-scale randomized controlled trial (RCT) of what happens to people when they gain Medicaid eligibility shows no impact on objective measures of health. Utilization went up, out-of-pocket expenditure went down, and the freqency of depression diagnoses was lower. But on the three important health measures they checked that we can measure objectively--glycated hemoglobin, a measure of blood sugar levels; blood pressure; and cholesterol levels--there was no significant improvement.

 

 

I know: sounds boring. Glycated hemoglobin! I might as well be one of the adults on Charlie Brown going wawawawawawa . . . and you fell asleep, didn't you?

But this is huge news if you care about health care policy--and given the huge national experiment we're about to embark on, you'd better. Bear with me.

 

 

Some of the news reports I've seen so far are somewhat underselling just how major these results are.

 

"Study: Medicaid reduces financial hardship, doesn’t quickly improve physical health" says the Washington Post.

 

The Associated Press headline reads "Study: Depression rates for uninsured dropped with Medicaid coverage"

 

At the New York Times, it's "Study Finds Expanded Medicaid Increases Health Care Use"

 

I think Slate is closer to the mark, though a bit, well, Slate-ish: "Bad News for Obamacare: A new study suggests universal health care makes people happier but not healthier."

This study is a big, big deal. Let me explain why.

 

 

 

 

 

 

The Data Speaks

 

Sadly, for some reason the results of the second year study were delayed. That's a real pity, because many voters going to the polls last November, and governors considering whether to do the Obamacare Medicaid expansion this spring, would probably have liked to have had this data sooner.

 

Here's the net result:

 

We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant ef- fect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (−9.15 percentage points; 95% confidence interval, −16.70 to −1.60; P=0.02), increased the use of many preventive services, and nearly elimi- nated catastrophic out-of-pocket medical expenditures.

 

No statistically significant treatment effect on any objective measure: not blood pressure. Not glycated hemoglobin. Not cholesterol. There was, on the other hand, a substantial decrease in reported depression. But this result is kind of weird, because it's not coupled with a statistically significant increase in the use of anti-depressants. So it's not clear exactly what effect Medicaid is having. I'm not throwing this out: depression's a big problem, and this seems to be a big effect. I'm just not sure what to make of it. Does the mere fact of knowing you have Medicaid make you less depressed?

For that matter, I'm not sure what the policy implication is. If you wanted a program to cure depression, Medicaid is probably not what you'd design.

 

So back to cholesterol and blood pressure, which are exactly the sort of thing Medicaid is supposed to take care of. What does this study tell us? That Medicaid--or health insurance more generally--is useless at curing physical disease?

 

Not quite. Oh, to be sure, Slate is right that this is not good news for Obamacare--which, you may recall, got half of its coverage expansion by putting more people into Medicaid.

There's been a bit of revisionist history going on recently about what, exactly, its supporters were expecting from Obamacare--apparently we always knew it wasn't going to "bend the cost curve", or lower health insurance premiums, or necessarily even reduce the deficit, and now it appears that we also weren't expecting it to produce large, measurable improvements in blood pressure, diabetes, or blood sugar control either. In fact, maybe what we were always expecting was a $1 trillion program to treat mild depression.

Well, that's not how I remember it; as I remember it, Obamacare was going to save tens of thousands of lives every year. And it's hard for me to look at this study and see the kinds of numbers that save tens of thousands of lives every year.

 

You can squint hard at the data and say, well, sure, the effects weren't statistically significant, but there was some improvement! Much such squinting has been going on. But if there had been a slight, not-statistically-significant decline in the health of the Medicaid participants, I'm skeptical that many--or any--of our squinters would have been touting the probative power of those sorts of small effects. As someone I was talking to earlier noted, "It's got huge confidence intervals" is not normally the sort of thing you hear when arguing that a study supports your thesis. Our intuitions about health care, not the data, are doing a lot of heavy lifting here.

 

When you do an RCT with more than 12,000 people in it, and your defense of your hypothesis is that maybe the study just didn't have enough power, what you're actually saying is "the beneficial effects are probably pretty small". Note that we're talking about a study the size of a pretty good Phase III trial for Lipitor, Caduet, or Avandia--some of the leading new drugs for treating high cholesterol, hypertension, and diabetes. Of course, to be fair, those trials enroll only people with the disease they're targeting, so you should get more statistical power--but then, to also be fair, many of those studies have many fewer than 12,000 participants and still achieve statistical significance.

 

And as Katherine Baicker, a lead researcher on the Oregon study, noted back in 2011, "people who signed up are pretty sick". Yet the study failed to find statistically significant improvement on the three targets associated with the most common chronic diseases. This, mind you, is the stuff that we're very good at treating, and which we're pretty sure has a direct and beneficial effect on health.

 

Hypertension meds and insulin/home blood sugar monitoring are not quite up there with antibiotics as a 20th century medical miracle, but they're in the Top 5. By one estimate I've seen, hypertension control has cut the death rate from stroke in half, and from heart attacks by a third. And as medical interventions go, it's easy: low cost, low effort, fairly minimal side effects. The hardest part is to convince patients to keep taking the pills, because hypertension has no painful symptoms until oops! major cardiovascular event.

 

Statins have more side effects, and diabetes control is much more onerous. Still, I'd have expected to get more power out of a study that treated 6,400 sick, poor people who previously had no insurance.

 

Another way to look at it is to think about the "number needed to treat"--which is to say, how many people do you need to treat to avoid some bad outcome? The estimate I've seen is that you need to control severe hypertension in 29 patients to prevent a single stroke in a five year period, and if the hypertension is less severe, that NNT rises as high as 118. According to the Oregon study, an extra 85 hypertensives got their blood pressure into the normal range, compared to the control group. So by putting 6,400 people onto Medicaid, we may have prevented as many as three strokes every five years, or as few as none.

It's worth noting, as Josh Barro pointed out on Twitter, that the average diastolic blood pressure of the Medicaid patients declined by only 0.81 points. This does not suggest that all 85 were achieving very large declines in their blood pressure. Either a few people got a lot of control, or a lot of people dropped a few points below a somewhat arbitrary cutoff line. By which I mean that cutting your blood pressure from 111 to 109 does not drastically decrease your stroke risk, but it will move you from "hypertensive" to "reasonably well controlled"

 

But that doesn't mean Medicaid has no effect on health. It means that Medicaid had no statistically significant effect on three major health markers during a two-year study. Those are related, but not the same. And in fact, all three markers moved in the right direction. They just weren't big enough to rule out the possibility that this was just random noise in the underlying data. I'd say this suggests that it's more likely than not that there is some effect--but also, more likely than not that this effect is small.

I don't want to understate either, however; these are the major chronic diseases we should be expecting Medicaid to help. I saw it suggested on twitter that the perhaps much larger effects on cancer, Parkinsons, and Alzheimers would take much longer to detect. In fact, it would take decades, since the majority of the new Medicaid patients were under the age of 50, and the average age of onset for those diseases is, respectively, 67, 60, and 72. Treatment effects would take even longer to discover, but unfortunately, we wouldn't actually discover them, since the majority of people with those diseases get treated on Medicare already. There's no control group to compare them with. <a name="body_text52" style="visibility:hidden">

 

And even if these design issues somehow withered away, there would still be arguing, because in slow-progressing diseases, it is easy to confuse early detection with prolonging life. If you've got a disease that's bound to kill you by the age of 85, and I discover it at 72 instead of 84, I've dramatically increased your "survival rate", but I haven't actually helped you survive. This has been a common refrain from critics of the American health care system when the system's boosters point out that America does really splendidly on cancer survival rates.

 

 

 

The findings are fascinating, if you have the time and have an interest in this, I'd read the rest of the article.

[B-Man]

Same story in Reason Magazine:

 

More Bad News for Obamacare: Study Finds Medicaid Has No Effect on Measured Health Outcomes

 

This is huge, and stunning, even for critics of Medicaid: A randomized-controlled study published in the New England Journal of Medicine by a group of the nation's top health policy scholars has found that Medicaid has no measurable effect on any of the objectively measured physical health outcomes the study examined.

 

 

In its second-year results, the Oregon Health Insurance Experiment, which randomly selected 10,000 people in Oregon to get Medicaid (only about 6,300 actually got the benefit), and then compared them with a randomly selected control group, found that those who got Medicaid did not on average have healthier blood pressure, cholesterol levels, or diabetic blood pressure control than those who did not get Medicaid. Those with Medicaid did see some reduction in out of pocket health expenses. They were also less likely to be diagnosed with depression.

 

 

The Medicaid recipients also ended up utilizing a lot more health care—care that has to be paid for—than those who didn't get coverage. But they didn't use the emergency room any less than the control group.

This study is perhaps the best and most important study of Medicaid's health effects ever conducted, and it has huge implications for public policy—in particular for Obamacare's Medicaid expansion, which is supposed to account for about half of the law's increase in health coverage. Obamacare supporters had used the results from the study's first year, which showed large gains in self-reported health, to argue that the law's expansion of Medicaid was justified. The second-year results significantly complicate that argument.

 

 

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[B-Large]

Why would insurance coverage have any effect on indicators such as cholestrol, BP or any other measure? Its simply the payment mechanism. Coverage doesn't mean people will change habits or comply with prescribed treatments....

[B-Man]

Why would insurance coverage have any effect on indicators such as cholestrol, BP or any other measure? Its simply the payment mechanism.

 

Coverage doesn't mean people will change habits or comply with prescribed treatments....

 

 

You and I know that sir, but in 2009 and 10, the "increased coverage part of ACA was sold as an eventual "cost cutter", because the expanded access to testing would cut down of fture treatments and need for costly interventions.

 

This is not the case.

 

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Edited May 3, 2013 by B-Man

[Magox]

Why would insurance coverage have any effect on indicators such as cholestrol, BP or any other measure? Its simply the payment mechanism. Coverage doesn't mean people will change habits or comply with prescribed treatments....

 

Whatever the case may be, the findings show based on the large sample size they conducted, that Medicaid hasn't helped people in an appreciable manner in some of the major metrics they use to determine the effectiveness of coverage. From my perspective, it IS worth noting, considering the major cost that is being spent at both the Federal and State level.

 

It seems quite obvious to me at least that there needs to be major reform with Medicaid. If you are going to spend this sort of money, specially considering the burden it creates at the State budget level (In which they have to balance their budgets, which means it comes at the expense of jobs, services etc), then they should be worried with these findings. You don't want to throw good money after ineffective programs right? And now couple that with the monumental expansion of Medicaid that we will be undertaking because of the ACH. It certainly gives pause. Don't you think?

Edited May 3, 2013 by Magox

[....lybob]

I'll tell you why a year study doesn't mean much to me when it comes Blood pressure, cholesterol and Glycated hemoglobin, most doctors will give patients 6 months to a year to see if they can make enough life style changes to correct the problem without medication, most can't or won't and then will be put on medication - show me a study that goes out five years then I'll consider it.

[B-Large]

Whatever the case may be, the findings show based on the large sample size they conducted, that Medicaid hasn't helped people in an appreciable manner in some of the major metrics they use to determine the effectiveness of coverage. From my perspective, it IS worth noting, considering the major cost that is being spent at both the Federal and State level.

 

It seems quite obvious to me at least that there needs to be major reform with Medicaid. If you are going to spend this sort of money, specially considering the burden it creates at the State budget level (In which they have to balance their budgets, which means it comes at the expense of jobs, services etc), then they should be worried with these findings. You don't want to throw good money after ineffective programs right? And now couple that with the monumental expansion of Medicaid that we will be undertaking because of the ACH. It certainly gives pause. Don't you think?

 

Medicaid is a tricky beast. I find the people who are on Medicaid fall into 2 catagories: People who are on it temporarily, they use it while they are in a tough position but have the itent of getting off of it and back to theirown employer based coverage. The other group are the lifers who see it as an entitlement- now, this is anecdotal, but i have been in the hospital long enough to hear numerous times "I am not paying a $2 copay" and that is the same group who is down in the cafeteria who orders burgers, fries and rings or has McDonald's in tow whiel they are here. Again, anecdotal, but I assume that second group could care less about health measures, doig their part to help contain costs or promote overall healthiness... So the question is what can be done to direct people's behaviors into positive versus negative expression? I don't know, but I do know when you are required to pay out of pocket people use less and respect it more. But you don't have a job, don't pay any taxes, and relatively low value of the scenery around you- why would you see the program any other way than someting that owes you?

 

Expansion of Medicaid is a logical step in expanding coverage to the poor- the program exists, its got track records of success it is goal, there are systems in place to identify and prosecute fraud. However, why not take that program and let each State figure out how they will deliver the program- I had no issue with block granting the program, is the State wants to fund over what they used to get from the Fed, then they can put it to the voters to decide if they want to fund it.

 

Coverage does not equate to better outcomes and measures, that goes for all coverages- it just stings more knowing the people on Medicaid are gettig the cow for free, the milke for free, and expect it.

 

I'll tell you why a year study doesn't mean much to me when it comes Blood pressure, cholesterol and Glycated hemoglobin, most doctors will give patients 6 months to a year to see if they can make enough life style changes to correct the problem without medication, most can't or won't and then will be put on medication - show me a study that goes out five years then I'll consider it.

 

Don't you agree that coverage does not necesarrily promote increases in those measure, though? Its a personal choice that I am going to lose weight and lay off the rings..... and I am sure you have one or two pateints that don't follow your advice, right??

[Magox]

Medicaid is a tricky beast. I find the people who are on Medicaid fall into 2 catagories: People who are on it temporarily, they use it while they are in a tough position but have the itent of getting off of it and back to theirown employer based coverage. The other group are the lifers who see it as an entitlement- now, this is anecdotal, but i have been in the hospital long enough to hear numerous times "I am not paying a $2 copay" and that is the same group who is down in the cafeteria who orders burgers, fries and rings or has McDonald's in tow whiel they are here. Again, anecdotal, but I assume that second group could care less about health measures, doig their part to help contain costs or promote overall healthiness... So the question is what can be done to direct people's behaviors into positive versus negative expression? I don't know, but I do know when you are required to pay out of pocket people use less and respect it more. But you don't have a job, don't pay any taxes, and relatively low value of the scenery around you- why would you see the program any other way than someting that owes you?

 

Expansion of Medicaid is a logical step in expanding coverage to the poor- the program exists, its got track records of success it is goal, there are systems in place to identify and prosecute fraud. However, why not take that program and let each State figure out how they will deliver the program- I had no issue with block granting the program, is the State wants to fund over what they used to get from the Fed, then they can put it to the voters to decide if they want to fund it.

 

Coverage does not equate to better outcomes and measures, that goes for all coverages- it just stings more knowing the people on Medicaid are gettig the cow for free, the milke for free, and expect it.

 

 

 

Don't you agree that coverage does not necesarrily promote increases in those measure, though? Its a personal choice that I am going to lose weight and lay off the rings..... and I am sure you have one or two pateints that don't follow your advice, right??

 

I'm not opposed to caring for the poor, as a matter of fact I endorse it, just that it needs to be done much more efficiently and effective than the status quo. As I mentioned earlier, whatever the case may be, it's clearly not working.

[B-Large]

I'm not opposed to caring for the poor, as a matter of fact I endorse it, just that it needs to be done much more efficiently and effective than the status quo. As I mentioned earlier, whatever the case may be, it's clearly not working.

 

Like the ACA is is working in providing coverage, but there is alot ot be desired in term of delivery and cost to be sure.

 

Like the ACA is is working in providing coverage, but there is alot ot be desired in term of delivery and cost to be sure.

 

I do get pissed when I see people who blatently work the system and flaunt it though. I want to say something, but I don't. But I'd like to.

[Magox]

I'll tell you why a year study doesn't mean much to me when it comes Blood pressure, cholesterol and Glycated hemoglobin, most doctors will give patients 6 months to a year to see if they can make enough life style changes to correct the problem without medication, most can't or won't and then will be put on medication - show me a study that goes out five years then I'll consider it.

 

It's not " a year study".

[Doc]

I'll tell you why a year study doesn't mean much to me when it comes Blood pressure, cholesterol and Glycated hemoglobin, most doctors will give patients 6 months to a year to see if they can make enough life style changes to correct the problem without medication, most can't or won't and then will be put on medication - show me a study that goes out five years then I'll consider it.

Wrong. It takes 2 to 3 months to see the full effect of a diabetic treatment change on HgA1c (glycosated or glycated hemoglobin).

[....lybob]

Wrong. It takes 2 to 3 months to see the full effect of a diabetic treatment change on HgA1c (glycosated or glycated hemoglobin).

patient comes in with diabetes or metabolic syndrome do you immediately put them on medication or do you try lifestyle changes first, if you try lifestyle changes first how how long will you wait to put people on medication if the lifestyle changes do not work.

[DC Tom]

patient comes in with diabetes or metabolic syndrome do you immediately put them on medication or do you try lifestyle changes first, if you try lifestyle changes first how how long will you wait to put people on medication if the lifestyle changes do not work.

 

Every doctor I know says: you put them on medication while trying lifestyle changes.

[B-Large]

 

 

Every doctor I know says: you put them on medication while trying lifestyle changes.

 

This must be part of that cost cutting effort we keep hearing about....

[DC Tom]

This must be part of that cost cutting effort we keep hearing about....

 

Everyone knows you only have to cut health insurance costs. Health care costs will then just magically come down...or something...