Oregon had a lottery to give Medicaid to some residents, and studied the result. Wingers are feeling good about their relentless poor-bashing because the study couldn’t conclude that Medicaid altered outcomes at the level needed to publish it as a scientifically valid finding. But, there’s this:
In fact, the study showed fairly substantial improvements in the percentage of patients with depression, high blood pressure, high cholesterol, and high glycated hemoglobin levels (a marker of diabetes). The problem is that the sample size of the study was fairly small, so the results weren’t statistically significant at the 95 percent level.
However, that is far, far different from saying that Medicaid coverage had no effect. It’s true that we can’t say with high confidence that it had an effect, but the most likely result is that it did indeed have an effect. The table below shows the point estimates. Note also that in all cases, the use of prescribed medication went up, in some cases by a lot.
Bottom line: It’s more likely that access to Medicaid did improve health outcomes than that it had zero or negative effects. It’s just that the study was too small to say that with certainty. For laymen, as opposed to stat geeks, the headline result of the Oregon study was “Possibly positive but inconclusive,” not “Had no effect.”
The general conservative position on Medicaid is a hot mess of contradiction and general stupidity. On the one hand, they want their uninsured almost-poor base to feel resentment towards the undeserving poors who are driving their welfare Cadillacs to the clinic every day to get some of that sweet, free Medicaid treatment that hard-working people can’t afford. On the other hand, since Medicaid is government-run healthcare, it is the devil’s spawn and can’t improve anyone’s well-being. Of course, Medicare exists on an ethereal plane completely separate from Medicaid. It is the God-given right of every freedom-loving American, provides excellent care and shiny new scooters, and must be kept away from the youngs, who would steal it from the olds if only they got a chance.
Betty Cracker
NPR did a crappy segment on the Oregon survey yesterday, which implied that Medicaid is worthless. They had some quack from the Heritage Foundation on to give the wingnut spin and no opposing viewpoint.
Brother Machine Gun of Desirable Mindfulness (fka AWS)
You’ve got wingnuts and math. If that isn”t a toxic combination, I don’t know what is.
cathyx
One would think that big pharma would love expanding medicaid because it provide drugs to people who wouldn’t otherwise get them.
Sister Rail Gun of Warm Humanitarianism
@Betty Cracker: I heard that. His objection to Medicaid seemed to boil down to “It won’t pay for the expensive procedures”, which made me very much want to look into how much of an ownership stake he has in those expensive specialty shops.
They also specifically said that there were no improvements in high blood pressure and cholesterol levels. To which I said “No shit, they still can’t afford a more varied anti-inflammation diet.”
Belafon (formerly anonevent)
If the study had covered three people, and their healthcare had gone down, it would have been published by conservatives as a full study on why medicaid needs to be shut down. And it would not need to be peer reviewed.
MM, you also missed the fact that a large chunk of Medicaid money goes to seniors on Medicare.
Liam
I think I heard that NPR thing yesterday. It turns out Medicaid has a price tag; poor people on Medicaid use more healthcare than uninsured poor people. Whoever was speaking was acting as if this was a totally unforseen consequence, and there was a bit of the ol’ McArdle “but is there evidence that access to health care improves health?”
mistermix
@cathyx: Big Pharma is afraid that the government will start negotiating down the price of meds once everyone is receiving government-run healthcare.
liberal
IMHO this part of the study might be meaningless, given that AFAICT doctors want to essentially put statins in the water supply.
cathyx
@mistermix: But wouldn’t they still be ahead of the game if more people could have access to the meds? As the price goes up, more people can’t afford them, stop taking them or never start taking them, and then they sell even less. But offering them to people who couldn’t otherwise get them, even with dropping the price, should still be more profitable to pharma than losing the customers.
Domino
As a guy in his low 20s, I enjoyed recently listening to Reagan giving a speech about how Medicare was the single greatest threat to liberty & freedom and would destroy everything good about America. Did he ever gets asked about how he felt about the program later in his life?
Todd
@Belafon (formerly anonevent):
More specifically, it goes to older white seniors on medicare and occupying medicaid beds in nursing homes after their adult progeny in their late 50s and 60s have carefully estate planned off the house so that the five year lookback doesn’t take “their inheritance”.
They need that inheritance for Jesus. WOLVERINES!!!!!
Cassidy
@Domino: I’m sure he did. He couldn’t remember the answer.
Elizabelle
@Betty Cracker:
Would only hear that from you, because I don’t listen to NPR any more.
NOTE: If I thought about it, would listen to Terry Gross.
drbloor
I don’t think Kevin fully grasps the meaning of “statistical significance,” which isn’t particularly surprising. The results of the study are inconclusive.
Kay
The part that’s interesting politically is how much guilt there seems to be among media and conservatives on denying low income people basic health care. They’re on defense.
There’s some kind of leverage there, possibly. I was listening to Kasich in Ohio (he’s pro Medicaid expansion, opposed by the Tea Party on it) and he’s making a really moral argument. I don’t know if he believes it, but he must think that somehow resonates with some segment of the GOP.
Roger Moore
@mistermix:
They’re at least as afraid that the government will also want to do other stuff that will hurt profitability, like enforcing the most effective treatments rather than the newest ones, and substituting generic drugs whenever possible. There’s so much waste that big drug companies know they’re going to lose out in any serious attempt to control costs.
NonyNony
@Kay:
He’s making the moral argument because he knows his audience and he knows that the economic argument would be refuted with a “nuh-uh it does not neener neener”.
The moral argument is a lot harder to refute because it can’t be refuted with a simple “no it isn’t” – they have to think about what Jesus would say. And, frankly, most of the Christians in Ohio do not seem to actually be worshippers of Randian Jesus and actually do think that helping the poor is occasionally important.
Also too – notice how he’s emphasizing that the rural areas are hard hit and will get a lot of assistance with this expansion. He’s trying to counter the overt racism that the anti-Medicaid expansion group has at its core by pointing out how much it will help rural citizens of the state, who “as we all know” are mostly white. (This is in fact true, but only because over 80% of our entire freaking state is white and so most of the people who get assistance from Medicaid in Ohio are, in fact, white. Not that you would know it from a lot of the racist Tea Party rhetoric that I get spewed on my Facebook page from relatives who live in the rural areas of the state…)
Roger Moore
@drbloor:
They’re suggestive but inconclusive. They show an effect that may or may not be real, but would be valuable if it is real. The obvious thing to do is to run a larger study to try to improve the statistical power of the current one.
aimai
@Kay:
I just bopped over here from reading the account in the sacramento bee of “greyhound mental health care” i.e. the State of Nevada dumps its mental patients on a bus and ships them off to California (and other states) in order to remove them from the books. Also there was just a story which I think I heard reported on NPR about a pilot project in–delaware?–which was incredibly successful at getting overall medical outcomes improved by dint of sending nurses to the homes of the chronically ill on a weekly basis. They had tried having nurses phone but that didn’t work. But a simple weekly home visit did the trick lowering costs and improving outcomes by thirty percent (IIRC) and because the majority of medicare/medicaid costs go to needless tests and repeat offenders (people who can’t maintain their chronic conditions without hospitalizations ) this was very signficant. However, for reasons that are unclear, they aren’t going to widen the program, its just coming to an end.
brettvk
@aimai: “However, for reasons that are unclear, they aren’t going to widen the program, its just coming to an end.” My first thought on reading this was that they can’t allow the success of a program to become widely known — that would imply that societal action creates positive results, and the entire project of our betters nowadays seems to be to persuade us that absolutely nothing can be done to improve anything for anyone in the 99%.
RaflW
@Betty Cracker:
This would be why I struggle to give NPR any money any more. They book Heritage
ClubFoundation mouthpieces as if Heritage isn’t a full of shit think tank.More broadly, the lack of understanding of science, the scientific method, statistics, and the complexities of health management mean that most reporters are totally in over their heads when it comes to something like this. Kevin Drum is a pedant and a middle-of-the-road squish. But he does know hw to unpack relatively complicated information.
NPR, which wants to be the go-to news source for pedantic, middle-of-the-road Americans could learn a thing or 12 from Kevin Drum.
RaflW
Edited for misunderstanding. Sorry.
Stella B.
Austin Frakt explains the results well.
patrick II
Avik Roy: While modern medical science has improved lifespan for most Americans by 20 years over the last century, when applied to poor people modern medicine just doesn’t work.
PurpleGirl
@aimai: IIRC, a similar program was tried in NJ (Camden?). Anyway, the results were positive — health improved and costs of repeat hospitalizations went down. I think the program was discontinued, but I’m not sure what happened to it. Was it too socialized? Was it helping the wrong people?
PurpleGirl
@patrick II: Why do you think so? Is that they are poor and don’t have the money for all the drugs, they aren’t able to comprehend what they need to do to comply with medical orders, by the time they get medical help the condition is too far gone to respond positively? All of the foregoing examples?
aimai
@PurpleGirl: It may have been new jersey. I can’t remember and since I heard it rather than read it I can’t find a quick link. I know there was another pilot project that used community clinic outreach extensively (but not nurse home visits) because that was written up in the New Yorker. There they zeroed in on the five or six medical disasters that were some few obese/diabetic/asthmatic patients who were clogging up the emergency rooms because they couldn’t get their issues under control and just went ahead and gave them what they really needed which was a steady primary care physician.
liberal
@patrick II:
By far and away, most of that increase in lifespan is not due to application of what we’d consider modern medical techniques. Most of it is improved sanitation, nutrition, and childhood infectious diseases, and some other fairly “basic” (albeit essential) stuff.
IIRC if we had a perfect cancer cure, it would only add a few years to life expectancy.
liberal
@RaflW:
Yawn. Most doctors are totally in over their heads.
Mnemosyne
@Betty Cracker:
I’m not sure they were talking about the same study on the NPR show I was listening to (briefly) in the car, but one of the hosts pointed out that the statistics on the study got skewed halfway through because the state of Oregon was able to dig some more money out of the budget for Medicaid and the study’s organizers (rightly) decided that it would be unethical to withhold Medicaid coverage from people in the control group who wanted it, so that shrank the control group to the point where it may have affected the overall statistics.
liberal
@Stella B.:
Yes, but he makes an important point that some people here don’t seem to understand:
PurpleGirl
@aimai: We know what works to help keep people healthy (or healthier). We know these “simple” actions help keep costs of other actions either down or in line. What we don’t have as a society is the will to help all people. And that is immoral.
RaflW
@PurpleGirl:
Costs going down = revenue, perhaps profit also going down. This is the key flaw with US health care: the money that goes to the bottom line is in resisting efficiency. The barring of negotiating prescription prices in Medicare D is the clearest signal that the market is more important that the patient or cost-control.
When wingers decry so-called rationing of health care, they’re just plainly stating that eliminating wasteful or fraudulent testing and procedures is to be resisted. These same people will claim that half of all gov’t spending is waste, fraud and abuse. But their doctor/clinic/HMO? Oh heavens. As squeaky clean as they come. Fools.
Villago Delenda Est
@Betty Cracker:
Everything that lives within the walls of the Heritage Foundation needs to be ruthlessly slaughtered.
patrick II
@PurpleGirl:
It was my lame attempt at irony. If you have cancer you see a doctor or die — rich or poor.
Kay
@aimai:
Sad. We’ve had really good experiences with using in-home nursing visits for (adjudicated incompetent) seriously mentally ill adults who are stable.
The nurses will check in as often as 4 times in 24 hours (although I’ve only ever requested 2X daily) and that allows the person to live independently (somewhat- they live in the equivalent of assisted living apartments) rather than being hospitalized.
It’s also cheaper, and they’re all on Medicare or/and Medicaid.
liberal
@RaflW:
This is a key point. It’s why even single payer (in the absence of a complete change in the way health care providers are reimbursed) isn’t enough to control exploding health care costs.
PurpleGirl
@patrick II: Okay. Well, it gave me a chance to make a few more points.
liberal
@patrick II:
Or if you have prostate cancer, (in many cases) you see a doctor, get it removed and become incontinent, or don’t see a doctor, and die with the disease rather than from the disease.
terraformer
@Roger Moore:
Exactly. If the goal was to determine whether there was a positive (or a negative) impact, it is curious that the study’s designers didn’t conduct a simple power analysis to identify a sample size that would provide the data they (apparently) wanted.
As we know, we’re up against a foe who uses scientific results only when they support a belief – and never otherwise – so it’s counterproductive to run a study that gives fodder for the nincompoops like this.
rikyrah
so, poor people don’t need healthcare and should just DIE ALREADY
Chet
Look, even at 95% confidence interval you’ll commit Type 1 error and see a “conclusively positive” result where there is none in one out of every 20 experiments. There’s actually a very good reason to treat “statistically inconclusive at 95%” as “negative result.”
@Roger Moore:
Well, ok, Roger, exactly how many people would you like to deny access to medical treatment in order to see if their health gets worse and their lives are shortened? There’s a critical ethical problem, here, with having a control group. See, “Experiment, Tuskegee Syphilis.”
Steve M.
So I assume that now Republicans who have good private healthcare are going to forgo all the medications and other treatments that are said not to be providing statistically significant health improvements for the poor.
Right?
drbloor
@Roger Moore: yeah, that’s what I don’t think Kevin gets.
Also, the study had 12000 people in it. If you need an even larger N to get statistical significance, your effect size is likely to be pretty I impressive.
drbloor
Unimpressive.
F******* iPhone.
aimai
@Kay:
The entire Nevada situation makes you realize afresh what a dangerously compartamentalized model of health care we have–people are free to roam around the country but they can’t take their medical care, or their coverage, with them and are at the mercy of a bizarre set of rules and regulations and providers that really don’t meet their needs. While its true that the majority of my medical needs will happen within a few miles of my home and I am far from transient that is not true for everyone, especially this vulnerable population who don’t have a primary care doctor or any stability in their lives: i.e. the homeless or people with fragile support systems. If we had a national health care policy that was truly comprehensive and…uh…national people who washed up in Nevada’s health care system and couldn’t be fully funded/cared for with Nevada’s money might be able to be covered and monitored under a federally administered program with local clinics tasked to serve everyone in the system regardless of where they came from originally.
**I’d also like to point out the horrible concordance of this Nevada story (in which the state makes its mentally ill homeless and expels them from the state) with the other recent big “mental ill” story about the scores of mentally ill/retarded adult males who were kept in virtual slavery in a turkey packing plant-farm for decades. This was just in the news because they “won” a big settlement from the now defunct Ohio corportation which had benefitted from their unpaid labor all those years.
aimai
@Chet: We should ask all the Republicans who vote against Obamacare and Megan McCardle who asserts that she thinks health insurance coverage does not materially improve health outcomes to volunteer for the other half of the double blind “doesn’t accept treatment” part of the program. Alternatively, you could match with identical patients in other states where they are being denied mediaid expansion by their republican overlords anyway. Apparently there are no ethical issues there.
Sister Rail Gun of Warm Humanitarianism
@liberal: Incontinence is not an automatic consequence of prostate surgery.
Though I suppose if one is lazy and doesn’t do one’s kegels, it could happen even with a perfect surgery.
Sister Rail Gun of Warm Humanitarianism
@drbloor: 12K people total. The people with the conditions they analyzed is necessarily a smaller number. Considerably smaller, from what I understand.
The only disease they got a substantial number of participants on was depression.
RaflW
@Chet:
Um, it’s not Roger who’s proposing denying care. Oregon ended up having a Medicaid lottery, so the immoral decision to cut people loose from care was already made. It was just that they didn’t sample enough from the ins and outs they created.
TriassicSands
Medicaid’s problem is that it is underfunded — oh, yeah, and before 2014 it was never really a health care program for the poor, it was always a health care program for only some of the poor.
The study recognized that Medicaid patients can have trouble getting appointments with specialists, but that’s because the specialists are following their own Hippocratic Oath, which states: First do no harm to your bank balance and investment portfolio.
Teresa
The only other thing that would have made the right wing happier is if the poor and elderly in nursing homes had died or suffered even more.
For today’s right wing if the rich aren’t making everyone miserable than it’s been a failed day.
TriassicSands
@liberal:
Unfortunately, liberal, medical science can’t tell which cases will be which. I don’t envy you the decision you’ll face if you discover you have prostate cancer. (Or if you’re a woman, someone close to you.)
Some thirty thousand American men die each year from prostate cancer, so it’s not exactly benign. And while we are in all probability over-treating prostate cancer, very few of those deaths are from over-treatment. The very real problem that men who have been diagnosed with prostate cancer face is not between certain incontinence or dying with the disease, but rather between the possibility of becoming incontinent (and/or impotent) and the possibility of dying from the disease. Most men would rather wear a diaper than a coffin.
If there are egregious cases of unnecessary treatment for prostate cancer, they are most likely among older men — 70 and older with low Gleason scores. But it’s not surprising that many men decide they’d rather be safe (and incontinent), than sorry and dead. Oh, wait, if you’re dead you can’t be sorry.
Of course, surgery is not the only option — both external beam radiation and brachytherapy (radioactive seed implantation) are quite successful in treating prostate cancer. Each has its own side effects profile, but guaranteed incontinence is not true in either case.
As for costs going up with expanded Medicaid. I would certainly hope so, since not going to the doctor is not less expensive medicine, it’s no medicine. in the long run, I’d also expect increased costs, since I would expect people to live longer, especially if seeing medical professionals regularly could help change American’s poor lifestyle choices. However, poor choices are not always the culprit; genes can be fatal. And when not fatal, damn expensive.
johnny aquitard
Dood. Conservatives are a hot mess of contradiction and stupidity.
liberal
@TriassicSands:
All the evidence I’ve seen is that prostate cancer is, in the aggregate, almost certainly overtreated.
Frankly, that’s just stupid. It depends on the NNT.
By your reasoning, no one would ever drive a car anywhere, since one possible outcome of a car trip is death.
TriassicSands
@liberal:
Unquestionably, it is over-treated. Sadly, the aggregate never gets prostate cancer, nor does it have to make a decision about treatment. That burden falls on individuals.
Apparently, your knowledge of prostate cancer and perhaps cancer in general is from what you’ve read. You don’t sound at all like someone who has faced a positive biopsy result and had to make a decision about what to do. If your Gleason Score is 2 or 3 or even 4 and you’ve got a relatively low PSA, then watchful waiting is probably what you should do. Unless, of course, you have a family history of prostate cancer and say, your father died from it. Personally, I think prostate surgery is overused or should I say over-selected by patients, but I also think that for many men the word cancer makes rational decision-making a lot harder. And there seems to be a strong feeling, at least among some men, that the thing to do with cancer is get it out…now! The idea of subjecting oneself to radiation — hey, doesn’t that cause cancer too? — is not one that a lot of men are comfortable with. Taking it out sounds so much more final than merely trying to kill it in place.
I have absolutely no idea where that came from. Unlike some people I avoid name-calling and the like in blog comments, but that made it tempting. I can’t imagine what made you conclude that from what I wrote. And, not surprisingly, you’re totally wrong. No surprise there.
I know a little something about what I’m writing, because my father and uncle died from prostate cancer and I currently have prostate cancer. I’ve spoken directly with many, many men who have the disease and who have chosen among the options for treatment. I’ve also discussed the subject at great length with some very fine urologists, radiation oncologists, and medical oncologists at one of the best cancer centers in the United States (U. of Washington Medical Center). You may think the diaper/coffin statement was stupid, but those very words were said to me by a prostate cancer patient: “I’d rather wear a diaper than a coffin.” I understood exactly what he meant. That you don’t says more about your experience level and empathy than it does about his intelligence (or mine).
If you are ever diagnosed with prostate cancer, and the state of knowledge and treatment options have not changed greatly from today, your attitude will most likely change. The doctors won’t be able to tell you how fast your disease will progress or if you will die with it or from it. If you’re fortunate enough to have a low Gleason Score and you’re already 70 years old, then watchful waiting may well be a relatively easy decision to make. I’ve talked with a number of men in exactly that situation and they decided they’d rather risk surgery than death from prostate cancer. (Incidentally, prostate cancer commonly metastasizes to the bones, and death from prostate/bone cancer is a grim way to die.
I have no doubt that prostate cancer is over-treated. More than one specialist has admitted exactly that to me. And it wasn’t something I had to pry out of them. The problem is the uncertainty about outcomes means that doctors can’t tell you with certainty that you’ll be OK. I have no doubt whatever that older men, especially those with other adverse health conditions, are being treated when they could safely monitor the disease, at least in the short run. But the idea of having untreated cancer in your body — slow-growing or not — is not a comfortable feeling. It’s one that many men refuse to live with, regardless of their age or Gleason Score.
Nancy Irving
@Chet: @Chet:
“Well, ok, Roger, exactly how many people would you like to deny access to medical treatment in order to see if their health gets worse and their lives are shortened? There’s a critical ethical problem, here, with having a control group.”
Apparently a number of GOP governors are going to provide us with such a control group–the ones who are rejecting the ACA Medicaid expansion.
TriassicSands
@Nancy Irving:
Nancy, it’s not an ethical problem at all — they’re poor people — letting them die is the humane thing to do. Just ask any Republican. I can’t count the times I’ve read some Republican quoted as saying Medicaid is worse than no insurance at all. Certainly, the Medicaid program Republicans would like to have would be worse than no insurance at all, because apart from requiring poor people to have skin in the game (translation — they’ll have to pay more money than they have), there would also be the mandatory shaming aspects of the program. For example, Medicaid recipients might have to have a huge “L” (for loser) or “T” for taker tattooed in the middle of the forehead, so everyone would know what worthless parasites they are.