On the Oregon Medicaid study: “Keep calm and collect more data”

The New England Journal of Medicine sent out a press release Wednesday evening with the click-bait title of “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes” (abstract here, the full paper is gated). Some background: because of a lack of funding the state of Oregon conducted a lottery system for Medicaid enrollment, and the ensuing results are being studied as a rare randomized controlled trial (RCT). The lottery has allowed healthcare researchers to, essentially, study the effects of Medicaid coverage in a way that people can begin to talk in terms of empirical causality. The first results (see here & here) were promising; for those who ‘won’ the lottery Medicaid appeared to provide increased health benefits and greater income security. This second result, however, is a little bit more mixed:

Let’s review. The good: Medicaid improved rates of diagnosis of depression, increased the use of preventive services, and improved the financial outlook for enrollees. The bad: It did not significantly effect the A1C levels of people with diabetes or levels of hypertension or cholesterol.

There is much, much more on this from folks smarter and more able to suss out the details behind this study than I can. For a wonderfully BS-free version go see Matt Yglesias’ take. I’ve read them all and so should you. For what it’s worth, on matters such as these, at the very least you will should be reading the folks at The Incidental Economist (where the above quote comes from). They’re serious, fair, and do this sort of thing for a living.

Unfortunately it was also an opportunity for some conservatives to, what in some cases I can only describe as gloatingly, declare everything they’ve ever argued negatively about Medicaid as validated. That is, yet another opportunity for them to delegitimize the program. I won’t bother linking to those simply because their arguments are (to be polite) disingenuous at best, or (to be impolite) a massive dollop of conservative derp at worst.

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Unequal Mussings

From Ezra Klein over the weekend, the appropriately titled “Paul Ryan’s inequality plan increases inequality,”

“Paul Ryan’s 15-page response to the Congressional Budget Office’s inequality report can be summed up in two sentences: Inequality isn’t a problem. But if it is a problem, then the ideas I’ve been pushing all along will solve it.”

Except, you know, his plan doesn’t reduce inequality…if it exists, that is. One the more frustrating things about this recent episode of discussions on inequality is trying to find accord from some on whether it exists. As I’ve said in the past, though, Gini don’t preach. On Medicare:

“A century ago,” Ryan writes, “the average American lived a life that was dramatically different, in terms of what he or she could experience and obtain, from an elite like Rockefeller. In many important respects, the difference between ultra-elites and average Americans is less pronounced today.”
“But that difference is less pronounced in large part because of programs like Medicare, which ensure that poor and middle-class seniors have access to health care of similar quality to that of richer seniors. So where Ryan’s analysis suggests the need to means-test Medicare and control health-care costs to ease inequality, the core of his health-care plan, the very plan he touts in the conclusion to his paper, would dramatically increase absolute health-care inequality for seniors.”

That’s because Mr. Ryan’s plan for Medicare is to shift the future increase in healthcare costs from the federal government to future seniors. What about taxes?

“In 2010, the Tax Policy Center released a detailed analysis of the tax provisions in Ryan’s Roadmap for America. If you were in the top 1 percent, they found, Ryan’s plan would save you $350,000 a year. If you were in the middle of the income distribution, it would cost you $152 a year. And if you were in the bottom 20 percent, it would cost you $393 a year. That would undoubtedly increase inequality.

Well that works out well if your wealthy, not so much if your not. Yet of course the entire idea of Mr. Ryan’s proposal is that those differences won’t matter because the inevitiable explosive economic growth would make everyone richer. Except, it doesn’t seem to work that way in the real world:

“Over at the International Monetary Fund, Andrew Berg and Jonathan Ostry recently published a paper looking at the relationship between inequality and growth across the world. In a sense, they were testing Ryan’s proposition exactly. “Some dismiss inequality and focus instead on overall growth — arguing, in effect, that a rising tide lifts all boats,” they write. Berg and Ostry found that “high ‘growth spells’ were much more likely to end in countries with less equal income distributions.” Moreover, “the effect is large . . . closing, say, half the inequality gap between Latin America and emerging Asia would more than double the expected duration of a ‘growth spell.’ ” And it was robust: “Inequality seemed to make a big difference almost no matter what other variables were in the model or exactly how we defined a ‘growth spell.’ ”

Which is a roundabout way of saying that spells of high economic growth inandofthemsleves don’t reduce inequality. Now, as Ezra notes, Mr. Ryan does bring up good points. Federal transfers in the form of Medicare and Social Security have become more regressive in the past thirty years. Explosive healthcare costs are the culprit there and do need to be dealt with, but simply plopping seniors into regulated exchanges with a voucher that buys less care over time is not a satisfactory solution in my eyes.

SCOTUS Gone Wild

     Whew! Earlier I wondered in a tweet whether there was anyone else in my small town eagerly awaiting a 10 a.m. SCOTUS announcement. There was no response, so, yeah. Anyway, here we go! 

WASHINGTON — The Supreme Court on Monday agreed to hear a challenge to the 2010 health care overhaul law, President Obama’s signature legislative achievement. The development set the stage for oral arguments by March and a decision in late June, in the midst of the 2012 presidential campaign.

     This is, of course, the big one everyone’s been waiting for. SCOTUS agreed to hear, out of all the various challenges, the 11th Court of Appeals decision that struck down the individual mandate but nothing else in the law. By choosing this over other lawsuits SCOTUS will be able to discern whether or not the rest of the law must be struck down if they find the individual mandate unconstitutional. Over at WonkBlog Sarah Kliff has a straightforward FAQ on the whole matter. My favorite point:

What could the Court rule? The Court could rule that the health reform law is constitutional and allow it to move forward.

It could also rule, as the 11th Circuit did, that the individual mandate falls while the rest of the law stands.

The justices do, however, have another option: The Court could decide that the individual mandate is so key to health reform law that, if it falls, the whole law comes down with it.

There’s also the possibility that the Supreme Court could decide that the case isn’t ripe to be heard yet, since the individual mandate has not been implemented. This would be similar to the ruling that came out of the 4th Circuit Court of Appeals and would essentially tell the law’s opponents they can’t come back with a challenge until 2014, when the penalties for not purchasing insurance kick in.

     Needless to say, oral arguments in the spring followed by a decision at the end of June next year will make for a busy news cycle. 

Look, It's Complicated

From Aaron Carroll over at The Incidental Economist. Post-debate thoughts from the realm of healthcare. My favorite:

Rep. Paul wants to go all medical savings accounts. That’s not a health reform plan. They exist already. He also wants to free the markets.

I would also add that he wants a return to the “doctor-patient relationship,” that jives with my congressman’s sentiments. My only issue is…I’m not exactly sure what that means. Furthermore, the “free the markets” line is getting a little old. It just doesn’t seem like a panacea to every societal issue to me, any more than “get the government to do it” would be. Yet I don’t hear from the other side of the spectrum that the solution to every problem/issue is the gov’t. Listening to last nights debate, you’d think we didn’t live in a mixed economy like most every other developed nation in the world.

Do read the rest of Mr. Carroll’s thoughts. TIE is an great place for healthcare insight.

Yup. Still Paying More

From a new Commonwealth Fund study:

It’s not a particularly unsurprising graph, as this trend is well established. 

Some other tidbits on healthcare among OECD (Organization for Economic Co-Operation and Development) countries:

1. Percentage of U.S. adults who went without care in the past year because of costs: 42 (second highest was Switzerland at 18%)

2. Average number of physician visits per capita in U.S.: 3.9 (OECD average was 6.3)

3. Diabetes lower amputation rates per 100,000 population age 15 and older, 2007 in U.S.: 36 (Median was 12)

4. Pharmaceutical spending per capita in U.S.: $956.00 (Median was $518.00)

Blurring the Lines

Ezra Klein has a cogent point about health policy overlap between the two parties in today’s Wonkbook. I imagine that ground level voters are largely ignorant of these similarities, being more tuned to the traditional political messaging.

“That’s always been the great secret of the Ryan plan. In proposing that we could dramatically cut costs simply by forcing seniors to choose private options on competitive exchanges, it affirmed one of the ACA’s central efforts at cost containment. Bowing to the unpopularity of that plan, Romney has now backed up to proposing we could dramatically cut costs by forcing seniors to choose between public and private insurance options on competitive exchanges — an even more liberal approach to cost containment. This ideological overlap has always been tense for both sides.”

PPACA: Episode VI “Return of the Lie”


By their own admission, the Obama Administration has conceded that an additional provision in Obamacare will not work. With the ending of the CLASS program, due to financial insolvency, it is time that we fully repeal this government takeover of health care and replace it with commonsense solutions that focuses on patients, access to quality care, and lowers the overall cost of health care.

(my emphasis)

The above quote courtesy of my House Representative Larry Bucshon on October 17, 2011. There has been an ongoing struggle in trying to inform people of what the Patient Protection and Affordable Care Act (dotingly described as Obamacare) actually means. The information I most impart, though, is that the PPACA is not a government takeover of healthcare. Here, I’ll emphasize it a little more clearly…THE PPACA IS NOT A GOVERNMENT TAKEOVER OF HEALTHCARE. Yet don’t take my word for it:

The phrase is simply not true.

Via PolitiFact, which rated it as 2010 Lie of the Year. It wasn’t true in 2009, and it isn’t less of a lie in 2011.

Those who are most responsible for providing accurate information for how legislation affects our lives should probably not lie. Well, actually, they should definitely not lie.  

A Third Way for Medicare

An interesting proposal from Phillip Longman on how to reform Medicare. Though I should point out that the ideas aren’t necessarily new, the timing is appropriate when presented with two unappealing alternatives to the status quo. Medicare’s fee for service structure does need reformation, but my question is whether or not removing the financial incentives for inefficient methodologies means we can’t create a financial incentive for methodologies that promote health wellness? Salary plus bonus?

The Right Questions

I love it when people ask the right questions. When it comes to big ticket items, like healthcare, the right kinds of questions can be really important. Now I’m not an expert on healthcare, or really anything for that matter. That may make me an especially promising candidate for punditry, but I don’t necessarily have the knowledge and perspective that comes from expertise to ask the right questions. Thankfully, others have.

Arron Carroll is a contributor to The Incidental Economist, a blog devoted to heath policy issues. Today he posted what amounts to an op-ed, “Do you really care about spending?” This is in regard to healthcare spending, and this question strikes me as the type we should be asking about the policies we support. If spending more on something doesn’t produce better results, then why do we assume spending more is inherently good? Mr. Carroll asks this question through the lens of pharmaceutical drug prices. 

This is a comparison of the drug prices for the 30 most commonly prescribed drugs in the world. As you can see, people in the US pay far more for those drugs than any other country. We pay twice as much for those drugs, on average, as the UK, Australia, the Netherlands, France, and New Zealand.

Think about that. The drugs don’t work any better here. The molecules in them are no different. You can’t argue this is about choice or freedom or formularies, since this is a comparison of the same drugs in each country. We just pay more for them. A lot more.

Do we like paying more just for giggles? I don’t know. Another good question is ”why – in a “free market” – are we paying so much more than everyone else in the world for the same exact pill?”

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