Medicaid in Oregon
First, the big one: yesterday afternoon kicked off a flurry of discussion - some of it rather heated - about the most recent paper (ungated version) to come out of Oregon’s Medicaid program. In case you’ve forgotten: a few years ago, Oregon had money to expand Medicaid enrollment - but they didn’t have enough to cover everyone who was eligible. So the state created a list of around 90,000 people, and enrolled 10,000 - giving people the opportunity to apply through a random lottery. That created an incredible research opportunity - the randomized design allows researchers to really see the effect of Medicaid enrollment on people’s health, and hopefully put to bed the nonsense idea that Medicaid is bad for people’s health.
The new publication is mildly disappointing in that regard - but the reaction to it has been way overblown. While the first study (which we wrote about in 2011) showed clear improvements in self-reported health, this paper is the first to report actual clinical data from the experiment. It did not find that Medicaid decreased average blood pressure, cholesterol levels, or HbA1c (glycated hemoglobin, a measure of blood sugar used as a diagnostic criterion for diabetes). The Medicaid group was far more likely to be formally diagnosed with and in treatment for diabetes. They also had much lower rates of depression (9% absolute risk reduction, meaning roughly one in eleven people was no longer depressed), and drastically lower rates of catastrophic medical spending.
As we noted, the results on cholesterol, blood pressure, and blood sugar are somewhat disappointing. But it’s crucial to put those measures in context. As usual, Aaron Carroll and Austin Frakt of The Incidental Economist have done incredible work pointing out the limits of the study, and the ways that it’s been over-interpreted. You should absolutely readtheirposts. They’ve also been active on Twitter, where Aaron has pointed out that the study may not have beenlarge enough to detect important effects on those variables, even if they were there, and that it’s not easy to reduce HB even when that’s what a study is specifically intended to do! We won’t spoil all of their points, but they’re excellent. Go read the post, and direct your friends to it.
As a final note on the Medicaid experiment, we’d like to point out that (while we appreciate the solid methodology) this is not the kind of study health care needs most. There is ample evidence that people benefit from insurance, both financially and medically. But our ability to benefit from access to medical care is currently limited by the massive flaws in the delivery system. Providing insurance to low-income people is great, but its value is drastically reduced when we’re spending a lot of that money on screening tests that cause overdiagnosis, unwanted elective surgeries, and expensive drugs that are no better than existing options. Eliminating the waste from the system is crucial to making universal coverage sustainable and affordable; we need RCTs of programs that focus on eliminating overtreatment and improving how we care for patients.
Elsewhere in the news...
This week, The New York Times Magazine featured a piece by Peggy Orenstein entitled,“Our Feel-Good War on Breast Cancer.” The article couldn’t be more timely, as research on overdiagnosis continues to highlight the downsides of widespread screening. It’s a nuanced discussion of Orenstein’s personal experience with breast cancer, and the “survivor” culture surrounding the disease. Definitely worth a read!
The Fountain of Youth
Last weekend, Ezra Klein posted a great example of how politics, money, and bureaucracy influence the kind of health care we receive. Health Quality Partners (HQP), created by Medicare with funds allocated by the 1997 Balanced Budget Act, provides seniors with a home visit from a nurse on either a monthly or weekly basis. The program was an incredible success, lowering spending on enrollees’ health care by 22%, improving their quality of life, and reducing their hospitalizations by 33%. But even though it’s been labeled “The Fountain of Youth,” HQP’s funding is due to expire in June of this year and it’s unlikely that a similar program will take its place. Even more unfortunate is that HQP’s success won’t be used to inform future programs. Instead, Medicare is creating a new generation of programs meant to shift from a fee-for-service system to a pay-for-quality system, arguing that the results of HQP were limited by its small size and that to scale-up the program would be less cost-effective than to change the payment structure that governs the entire program. Perhaps this analysis is valid, but the situation highlights the difficulty of reshaping an existing healthcare system in which so many have a stake.
"We torture people before they die.”
Jonathan Rauch profiles Dr. Angelo Volandes, creator of a series of videos showing patients the reality of aggressive end-of-life treatment, in this month’s Atlantic magazine. For the last several years, Volandes has been working on a series of videos showing patients what it's like to receive intense medical treatments like CPR, feeding tubes, and being placed on a ventilator, and helping them understand what benefits they can actually gain from medical treatment - and what they can't. When patients see those videos, the reality of aggressive end-of-life care hits home - and they're much less likely to choose aggressive, expensive, and often futile treatments.
Volandes's work highlights the importance of talking about death with patients and their families, and illustrates how much of end-of-life care is actually unwanted care. His videos help doctors and patients have what Volandes refers to as “The Conversation,” a necessary but often avoided discussion about the imminence of death and the need for a patient and his or her family to decide how far they want to push the boundaries of life-saving medicine. It's good to see docs like Volandes stepping up and pushing their profession toward having more honest, productive conversations about end-of-life care. We'll all die better - and live better - for it.
California End-of-Life Care
Unfortunately, patients don't always get what they want. In fact, many dying patients are subjected to far more intense treatment than they would have chosen. The new report "End-of-Life Care in California: You Don't Always get What You Want," by Senior Fellow Shannon Brownlee, highlights those discrepancies. Most people say they would prefer to die at home - yet huge fractions end up dying in a hospital. Hospice has been shown to have positive effects on quality of life without reducing lifespans, yet adoption of hospice remains slow.
The report also highlights the huge geographical variations in how much treatment dying people receive. In nearly every category, California lags behind other parts of the country. In many cases, Southern California particularly sticks out as a hotbed of intense treatment. Patients in that area should pay particularly close attention to this report - it has important implications for what their last few months might look like, and what we might do to make the medical system serve their needs better.
For more on the CHCF atlas, and how it connects to Rauch's story, see our post on In the Tank.
