Better signals for Obamacare success

Kevin Drum is laying out some markers for what he would consider an Obamacare success story in 2023.  He raises a good point about pre-65 mortality rates.

But my biggest issue is with the age-adjusted mortality rate. I know this is a widely popular metric to point to on both left and right, but I think it’s a terrible one. Obamacare exclusively affects those under 65, and mortality just isn’t that high in this age group. Reduced mortality is a tiny signal buried in a huge amount of noise, and I very much doubt that we’ll see any kind of clear inflection point over the next few years.

I think there are a couple of different metrics that would be fairly useful and fairly easy to get widespread agreement that these changes would indicate that Obamacare is working fairly well.  The biggest change would be  a significant increase in Quality Adjusted Life Years for people between the ages of 18 and 64.  A QALY is a way of valuing how good a year of health is.  The source of all knowledge gives a good definition:

The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for being dead. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or have to use a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this

QALY is a better signal than raw 18-64 mortality rates because right now, a 55 year old with chronic conditions is still strong enough and in good enough shape most of the time to get to Medicare.  However the time period between significant impairment and Medicare eligiblity is less than optimal health.  Improving health may not reduce the 18-64 mortality rate, but it dramatically improves quality of life while reducing costs.  The Boston Globe recently ran a story about active disease management for diabetes and highlighted the business case: 

About 60 percent or so people with type 2 diabetes can keep side effects at bay by simply managing sugar levels, exercising, and watching their weight, said Dr. Sam Nussbaum, a former endocrinologist at Massachusetts General Hospital and an executive vice president for the insurer WellPoint.

On the flip side, if the disease is ignored, it can lead to multiple, severe complications. It’s the leading cause of heart disease, strokes, kidney failure, and vision loss.

A relatively healthy person with diabetes can cost insurers around $5,000 a year.

‘‘But if you let any of those long-term, difficult complications develop, then you’re talking $100,000-plus,’’ Nussbaum said

Improved quality of life may not show up in mortality statistics, but the overwhelming majority of people strongly prefer vision over blindness, strongly prefer not going on dialysis, and strongly prefer not going through cardiac rehab.  There is a massive quality of life gain for an individual whose diabetes or other long term chronic condition is effectively managed because they now have access to affordable health insurance and thus affordable healthcare (where the insurers have the incentive now to engage in effective disease management) rather than the chronic condition only being intermittently managed or treated for acute flare-ups.

39 replies
  1. 1
    Another Holocene Human says:

    This whole conversation may be too technical for me, but doesn’t infant mortality come into this? Not everyone eligible for Medicaid before was getting it and access to care in an area with insurance market failure is spotty at best. Over time, there ought to be an improvement in infant mortality rates in the US as a result of this law. ESPECIALLY in states that expanded Medicaid to working adults. The old system only kicked in when you were pregnant but health prior to the early weeks of pregnancy is very important. Plus the entire household is under enormous stress when the working adults don’t have health insurance.

  2. 2
    Fair Economist says:

    I think mortality rates *are* going to be a good measure, especially disease-specific ones. The numbers are enormous, and we’ll have a control group in states that didn’t expand. It doesn’t take much of an effect to show up when your sample size is 150 million.

    QALY is great too, but it’s not collected on a population-wide basis.

  3. 3
    Richard Mayhew says:

    @Another Holocene Human: Definately, but honestly, infants had a patchwork system of coverage that was not quite universal but much more extensive pre-PPACA. Even in the sadist states, kids have a much easier time getting on Medicaid than adults.

    Looking for 2nd and 3rd order impacts like improved infant mortality rates will happen, but it is not the first impact I would expect to see.

  4. 4
    Tommy says:

    No don’t go here. I am 44. I often joke I don’t have aspirin in my house. I am blessed with amazing health. I work for myself. With that said my plan is $78 less per month and it is a better plan. That is what you say. Better and less money. KISS (keep things stupid simple).

  5. 5
    Richard Mayhew says:

    @Fair Economist: much in the same way BMI is not collected on a population basis, but it can be extrapolated.

  6. 6
    srv says:

    Is anyone going to track the number of small business startups and relate that to ACA?

    That HC is availabe to many that otherwise would be stuck in traditional drone jobs to support family healthcare, and now are free to experiment.

  7. 7
    piratedan says:

    man you guys are naive as hell if you think that showing the R’s any improvement in the general/overall health of the population matters.. They’re looking at everything from economic costs to medicare reimbursements for docs and even if there are economic benefits (to the nation, not their donators), I wouldn’t be surprised if they collectively whistle past that graveyard too.

  8. 8
    Citizen_X says:

    @piratedan: The R’s? No. The voters, on the other hand, yes.

  9. 9
    Another Holocene Human says:

    @Richard Mayhew: But it’s more than just infant care, right? Because the US has an extremely high infant mortality rate that is concentrated among poor communities of color and speaks to our unequal access to care. And the state that the mother is BEFORE she conceives, the state she’s in during early pregnancy, the stress that she and her family are under during the pregnancy and immediately following, these have a big impact on infant mortality. So it seems very likely to me that we’ll see an effect.

    Finland did the simple thing of providing clothes and other small items to every mother on the birth of their child and saw their infant mortality rate drop.

    Yes, we through Medicaid provide access to emergency care at birth. That’s why we don’t have a rate of fistulas rivaling West African nations and in fact most Americans don’t know what a fistula is. But we still have a lot of babies, way too many babies, die.

    I respectfully disagree that our former system was at all adequate. The numbers don’t lie.

  10. 10
    Another Holocene Human says:

    @Citizen_X: This is an end to two decades of “both sides sold us out” DLC garbage, if only we take it. I know there are some union people who already had good healthcare who for whatever reason have decided they don’t give a shit even though this law has affected them in positive ways.

    For example our union fought to get HepB vaccinations paid for and lost (b/c we’re exposed to blood borne pathogens on our job). But now they are free. Thanks, Obama.

    And our premiums over the last three years have not gone up as fast. And next year with more people covered we should start seeing somewhat better care. More urgent care clinics have opened, for example.

    I wish the stick in the muds would get unstuck and realize how huge this is. Get on the bus and fight like hell to get more and better Democrats elected. There’s so much more we can accomplish.

  11. 11
    aimai says:

    @Richard Mayhew: Yes but as Holocene point out a lot of health issues start prenatally–and a lot of those are affected by the mother’s state of health. If she hasn’t had health care for, say, the period between aging out of her parent’s health care/medicaid and gettign pregnant the fetus is fighting an uphill battle against low birth weight and a whole host of potential poverty related disorders. And then again after the baby is born a mother without health care coverage is not able to parent a child as well as a mother with health care coverage.

  12. 12
    piratedan says:

    @Citizen_X: the hard part with that is that those folks really do appear to be impervious to facts and data that falls outside their bubble of beliefs. I still want single payer but this is a vast improvement over MILLIONS being un and underinsured, just wish that the folks that made it happen could get some kudos for it and that we can see and end to all of the crap that I see on the tube telling me what a POS this law is courtesy of the Koch Brothers.

  13. 13
    D58826 says:

    It still amazes me the blind unreasonable hated that the GOP displays toward Obamacare. It almost seems that it has reached the point that these folks should seek medical help. If they obsessed about anything else their family would begin to worry about their mental health.

    And we are still left with the contradiction that a government and a president that are so incompetent that they can’t make water run down hill but can pull of this massive fraud right under everyone’s nose.

  14. 14
    smith says:

    @Another Holocene Human: Glad you brought this up. The possible effect of Obamacare on the US’s scandalously high infant mortality rate is something I’ve been looking forward to as well. I think that not only will the mother’s access to care prior to pregnancy improve her health and therefore the chances for her future babies, but, if it works as intended, the habit of seeking freely availble preventive care that Obamacare is designed to foster will help with adherence to prenatal care when the time comes.

  15. 15
    Jewish Steel says:

    OT, with apologies, but I’m obliged to get this great band name alert out. In the first sentence. Can you find it!

    My local rag.

  16. 16
    D58826 says:

    @smith: And it is ‘funny’ that the loudest pro-lifers and sanctity of the fetus are also the one most opposed to Obamacare and the benefits it would bring to expectant mothers and their babies.

  17. 17
    jl says:

    @Richard Mayhew: There are several National Center for Health Statistic surveys that collect BMI data, though precision of estimates might be too wide to detect turning points over the short term.

    I agree that there are several measures that should be used to evaluate the ACA. Certainly for fiscal planning, how it bends the ‘cost’ curve is one. Though think I will start referring to it as the ‘expenditure’ curve, since much of what we pay for health care (and other things) in the U.S. corporate oligarchy is not economic costs but economic rents and transfers.

    In my view, the real metric should be comparison of the U.S. to other high income industrial countries, almost all of which have better population health outcomes and lower costs than the U.S. And there are measures that can be used for international comparisons. Two are Healthy Year Equivalents (HYEs) and Disability Adjusted Life Years (DALYs). Look at the World Health Organization site for extensive explanation and research results.

    I think Drum’s reasoning on mortality is just plain wrong. Recalling the post by RM earlier today, we can ask ‘small compared to what’. In what sense are age adjusted mortality rates for older adults in the U.S. ‘small’? They are not small compared to young adults, or plain adult adults (say 35-44). They are not small compared to those of same age group in other high income industrial countries.

    These mortality rates should be dropping steadily and measurably over several years, judging by what has happened in other high income industrial countries with good health care systems. Recent research has strongly suggested mortality rates in older adults are INCREASING for poorer individuals of all races and ethnicities in the many areas of the U.S. And historically, the turn around in mortality rates can be quite dramatic over short to medium term after health care system access is improved. Portugal in the mid 1970s is an example, where the imposition of a good national health care system was one of the few good economic innovations of the coup by the Marxist generals. So mortality rates dropped dramatically, and life-expectancy rose dramatically over a period of ten years, even with the rest of the Portuguese economy in a mess. And Portugal, once the horribly and egregiously ‘sick man’ of Western Europe population health wise, now surpasses the performance of the U.S. in terms of life-expectancy for both sexes at a variety of ages. Estonia is another example, though I think the stats for men need to keep increasing for a few years to surpass that of the U.S.

    So, think mortality rates and life-expectancy are reasonable measures to consider. And mortality is connected the morbidity. Sometimes people speak of hip replacement as just a life style comfort issue. It is not, bad hips are related to falls, they are related to disability retirements and loss of income, and loss of income is very devastating to health status in the U.S.

    And RM may well have better information, but older adults are a group, from what I have heard from medical directors, currently is not a high priority group for adequate coverage even if they are insured. The strategy for them is to keep them patched up long enough to pass them on to Medicare and let the government handle the mess.

    I see no reason to rule out any of these measures. And the ‘compared to what’ question should always be kept in mind in measuring system success. Simple comparing changes in historical trends of population health in the U.S. would set a very low and unethical bar, in my view. Compared to most other high income, the U.S. has been a killing field, especially for adult women.

  18. 18
    🌷 Martin says:

    @Another Holocene Human: Infant mortality is a key goal to improve. The other is bankruptcy rate. That’s going to be a proxy for all sorts of quality of life/health measures.

    Obligatory video explaining survival rates vs mortality rates.

  19. 19
    jl says:

    @jl: And, my hunch is that changes in trends in measures of morbidity and mortality, when measured with vital statistics and national health surveys, will be strongly correlated. So what some do will reflect what others are doing over time.

  20. 20
    japa21 says:

    Although this will not, in all probability, be measurable for several years, I have to believe that the ACA will have a tremendous impact on Medicare costs. And I am not referring to those aspects of the law that are already focused on reducing the cost of Medicare. I would assume that, over a period of time, the overall health quality of people as they enter into the Medicare system will be better, thereby requiring less inital care.

    So at the least, per capita spending for Medicare should be reduced. At the same time, there will probably be an increase both in numbers of people reaching Medicare age and in the life span of those people, so that Medicare will be covering more people for a longer period of time.

    The question is to what degree the lower per capita cost will offset the increase in both number of people and length of time in the system.

  21. 21
    patrick II says:

    The success off obama care should not be measured just by improvements in health statistics. To majority of bankruptcies are caused by medicalbills. Large medical bills not leading to bankruptcy will also be decreased allowin
    g the people to live with less fear and more options. That all counts for something if anyone is counting.

  22. 22
    jl says:

    @japa21: I think so too. There has been some research on the effect of lapses in insurance coverage on population health and per capita health expenditure, both in public health and economics. The research shows that lapses in health insurance coverage is bad for health and bad for expenditures. At least two studies I have seen found is a practically and statistically significant effect on per enrollee Medicare expenditure. Merely having to change insurers and providers is also bad, but not sure the ACA will fix that. But the ability of more people to have continuous coverage should improve health and reduce expenditures.

    Don’t have the references at hand, but have been meaning to look for them on my computer. This effect would be in addition to improving care for older adults, who, as I said in previous comment, I have heard medical directors admit in meetings, are often not provided a reasonable standard of care, but merely patched up and passed on to Medicare as problems for the government to solve on the Medicare and taxpayer dime.

  23. 23
    Keith G says:


    Glad you brought this up. The possible effect of Obamacare on the US’s scandalously high infant mortality rate is something I’ve been looking forward to as well.

    The IMR will see improvement, but it’s improvement relative to many EU countries may not be as much as you think. The United States practices a very comprehensive definition of “live birth” that many other countries do not. When such statistical reporting differences are considered, the US becomes a lot more similar to Western Europe.

    Edited for muffed “reply to”

  24. 24
    hoodie says:

    Face it, most of these statistical measures will not be clear for many years. The most immediate measure is the level of turnout of supporters of ACA for off year elections. If the public benefitting from the ACA doesn’t get that a decent social safety net requires democratic participation, the statistics will float off into space behind a cloud of Fox obfuscation. The GOP is betting on that, which is one reason they’re doubling down on repeal. The main thing working in the ACA’s favor is people will think they have gained a significant increase in their perceived level of security, and will not want to lose that once they have it, even it it needs to be fixed. This is why the dems need to run on it, and it appears that Obama is trying to prod them in that direction.

  25. 25
    jl says:

    @Keith G: That is true, and probably best to go to the OECD health care statistics website for harmonized statistics and explanations of definitions in different countries and what adjustments are made.

    Also, U.S. statistics have been a mess until recently because individual states were not following uniform reporting methods. So there are funny jumps and jiggles in national statistics over last decade. Probably will need to check on NIH PubMed to find a good statistical analysis that straitens out the adjustments. U.S. Vital Statistics has been fixing the mess over the last few years, but has not gone back and adjusted all the state reports for harmonized national historical measures.

  26. 26
    Roger Moore says:


    The question is to what degree the lower per capita cost will offset the increase in both number of people and length of time in the system.

    I would expect the increased number of people to dominate. Most of the cost of health care is actually end-of-life care, trying to keep people alive for a few years longer at the end of their life. Since everyone is going to die eventually, you can’t prevent that from happening. The only way you get cost savings if if people die more rapidly.

  27. 27
    jl says:

    @Roger Moore:

    ” The only way you get cost savings if if people die more rapidly.”


    Best way to save money is to keep people healthy, at least healthy enough to be active until they are elderly.
    Basically, no smoking, moderate alcohol, decent diet and daily exercise and not too much stress. A simple recipe, but one beyond the means of the U.S., apparently.

  28. 28
    Roger Moore says:


    Best way to save money is to keep people healthy, at least healthy enough to be active until they are elderly.

    What I meant was that a huge fraction of the cost of our healthcare system is for the last few years of life when people are in their decline. As long as that decline phase is about the same length, he cost is likely to stay about the same regardless of the age at which people die. The money savings are in having people go from mostly healthy to dead faster; going to sleep and never waking up or being killed in a catastrophic accident are a lot cheaper than dying from Multiple Sclerosis. Letting people live longer by staying healthy is a great goal, but more because of the human good it does than because of any hypothetical cost savings.

  29. 29
    jl says:

    @Roger Moore: The longer people stay healthy, the older they are when they fall apart, and they are also frailer in terms of medical and surgical trauma that they can withstand in general (which is different than being healthy and active). They are able to withstand less very expensive medical interventions. People who can stay active and healthy until they are a decade or so into elderly years die cheaper, to put it rudely. I think that is what research is starting to show. When I have time I’ll look for a reference.

  30. 30
    inkadu says:

    @patrick II: This.


    Ask yourself if you’d rather have a certain illness go untreated for a few years, or if you’d rather have to declare bankruptcy. Bankruptcy sucks. It threatens your stability and takes away everything you’ve worked for. And, even better for us, bankruptcy is an easy thing to measure.

    PBS put out a documentary on “health care around the world” when Obamacare was being squeezed into its sausage casing. In every country around the world, they asked the same question, and it was almost always met with shock and horror: “So you don’t let people go bankrupt to pay medical bills?”

  31. 31
    Mnemosyne says:

    @Roger Moore:

    As long as that decline phase is about the same length, he cost is likely to stay about the same regardless of the age at which people die.

    I’m not so sure about that. I’m pretty sure my late father’s COPD and multiple bouts of smoking-related cancer were much more expensive than someone else’s non-smoking-related illnesses at the same age.

  32. 32
    Mnemosyne says:

    @Keith G:

    I think FYWP is not allowing more than one link — I was trying to say that maternal mortality may be a better measure of our improvement than infant mortality. Right now, the US ranks with Iran in having 21 women die out of every 100,000 who give birth. In the UK, only 12 out of every 100,000 new mothers die.

  33. 33
  34. 34
    Fluke bucket says:

    Facebook loon said antibiotics for her dog had gone up over 600% due to Obamacare. Wife took dog to vet today and said there were “due to Obamacare” warnings all over the office and they penciled in a $2.97 Obamacare surcharge for a rabies shot. I grow weary of the unrelenting bullshit.

  35. 35
    mclaren says:

    Once again, Richard Mayhew is lying to you — this time, by omission. Notice that Mayhew avoids citing this article by Kevin Drum: “Doctors Begin to Notice That Health Care Is Really Expensive,” Friday, April 18, Mother Jones.

    Let’s hit some of the highlights from Drum’s article, shall we?

    …plenty of doctors are already very cost conscious—but in the wrong direction, pushing lucrative, highly expensive treatments because it’s good for their own bottom line. Sometimes it’s because they have a part ownership in a diagnostic facility. Other times they’re just gaming the system, as some high-volume ophthalmologists do by routinely prescribing Lucentis ($120 reimbursement from Medicare) vs. Avastin ($3 reimbursement from Medicare) for treatment of macular degeneration. Guidelines that rein in this kind of behavior are an obvious target.

    And where is Richard Mayhew in citing this particular gem?


    Mayhew prefers to celebrate the alleged “success” of the ACA is increasing the number of patients insured and temporarily reducing the up-front costs of medical care out-of-pocket for patients — while Mayhew studiously ignores the fact that the ACA does absolutely nothing to force the kind of cost reductions Drum’s article discusses.

    Let’s be clear here, people: the ACA is not a “success” if it forces more people to pay for private insurance to get health care while simultaneously allowing the cost of medical care in America to skyrocket completely out of control. And that’s what happening. Health care in America is on a cost trajectory to the moon.

    Hepatitis C guidelines issued in January by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend the new drug Sovaldi with no mention of its cost.

    A full course of treatment with Solvadi costs a whopping $84,000.00.

    There’s a perfectly simple solution to the insane cost of drugs like Solvadi: the president can nationalize the big pharma companies and convert all scientists currently working for private industry into government bureaucrats. The drugs can then be developed by a branch of the NIH and sold at cost. Instead of $84,000, a course of treatment with Solvadi would then cost something like 8 dollars and 40 cents.

    The gross waste involved in letting private for-profit big pharma companies develop and market and profit from drugs is mind-boggling. Fully half the budget of the big pharma companies’ billions of outlays for new drugs gets gobbled up by marketing…not research or clinical trials.

    Richard Mayhew doesn’t seem to be interested in mentioning that fact in his posts.

    “Pharmaceutical companies spent 19 times more on self-promotion than on basic research,” Huffington Post, 5 August 2013.

    Mayhew has written a lot about health care in America, but he always leaves out little facts like this. I’m very interested to know why.

    Despite Mayhew’s phony claims that the ACA is a wild “success,” the plain fact of the matter is that the ACA does absolutely nothing to control these kinds of medical costs. And unless we get medical costs under control in America, the ACA is just a band aid on a severed aorta spurting blood five feet into the air.

  36. 36
    mclaren says:


    From Mnemosyne’s link:

    Uninsured pregnant women are eligible for Medicaid. But, according to the American Congress of Obstetricians and Gynecologists, they receive fewer prenatal care services, are more likely to enter pregnancy with health problems, and are more likely to have adverse maternal health outcomes.

    This is absolutely insane. Dumping poor people into Medicare where they get inadequate prenatal care is utterly crazy, because anyone can see that this kind of public policy hugely increases health care costs.

    Medicare that provides inadequate prenatal care greatly increases the chances of complications in pregnancy — complications that cost tons of money and require massive amounts of medical intervention to fix.

    Yet Richard Mayhew continues to tell us the big lie that Obama’s non-reform ACA is a “success.” Dumping poor people into a grossly inadequate lowballhealth care system like Medicare’s prenatal care system is a total failure all around — it’s a failure of public policy, it’s a failure of the the bean counters to do the simple math and recognize that when you give poor prenatal care to impoverished women, you are going to wind up paying for it down the road with complications in pregnancies that requires massive medical spending, and it’s failure of America’s entire scheme for providing health care. If you have two systems of health care, one which provides high-quality prenatal care for insured middle-class people, and another system of health care that offers inadequate prenatal care for poor people, who do you think is going to pay for the staffs of doctors performing 5-hour-long obstetric procedures to save the poor woman’s life or her baby’s life?

    Everyone. That’s who.

    Everyone is going to wind up paying.

    This is a no-brainer. Yet characters like Mayhew continue to trumpet the ACA as a vast “success.” If you consider health care coverage without regard to anything else as a “success,” then by all means, celebrate that — but some of us consider American women not dying in childbirth to be a better measure of success.

    Once again, the solution is simple, and I get called a troll and a lunatic and every other name in the book for pointing it out: single payer nationalized health care. It’s not a mystery. Other nations do it. You’re telling me America, the “can do” nation that put a man on the moon, can’t manage to do what Japan or Germany or the Netherlands or Spain, for crap’s sake, have done?

  37. 37
    tesslibrarian says:

    @Fluke bucket: Probably too late, but just in case…

    There’s actually a doxycycline shortage. It has nothing to do with Obamacare and everything to do with some production issues that caused a backlog. Doxycycline is the preferred first antibiotic when dealing with MRSA and some other hospital infections. My GP told me about this when prescribing it for a respiratory infection for me in February. The shortage has affected veterinary prices, since most vets don’t have the same deals with drug producers as insurance companies.

    Here’s the CDC info about the shortage.

    I get the frustration with unrelenting BS, but it’s nice to be able to say, “Quit lying to your customers.”

  38. 38
    Another Holocene Human says:

    @tesslibrarian: It’s a stupid dildo tax. Like the gun shop owners telling goobers that the bullet shortage is due to DHS or Obama. No it’s not, it started with some banksters speculating on base metals and continued with irrational exuberance, er, maybe just plain irrationality of bullet buyers keeping the price high by buying everything out because Obummer was gunna took er gunzzz and maybe ends with a switch to less toxic but somewhat more pricey copper shot, shortage being “oh we can supply it, Walmart, but not at that price”.

    The funny thing about the paranoid is that they are so easily manipulated while giving themselves the illusion of being in the know and smart.

  39. 39
    John M. Burt says:

    @inkadu: Not long ago, I mentioned medical bankruptcy and the guy curled his lip and said, “And how often does that happen?”

    I told him that it’s the single most common cause of bankruptcy in the U.S., and only in the U.S., but I doubt he believed either fact.

    How do you reach people like that?

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