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.