Justifying Cruelty

As yesterday’s post pointed out, Perry and the Texas GOP Left Me Out, there are many hard working Texans who are being denied Medicaid because of ideology. GOP state Sen. Charles Schwertner’s recent Op-Ed is an attempt to try and justify the cruel decision of the GOP to deny expanding Medicaid in Texas.

Schwertner focuses mainly on one aspect of the study relating to emergency room visits.

Earlier this month, Science magazine published the results of a randomized, peer-reviewed study detailing Oregon’s experience in expanding Medicaid to the same population of independent, able-bodied adults that Texas is now asked to consider. Despite showing no improvement in measurable health outcomes over the study’s two-year timeframe, those enrolled in Medicaid were actually shown to use their local emergency room 40 percent more frequently than a control group of the uninsured. The factors driving this result are twofold — convenience and a lack of access to alternative primary care.

An uncomfortable truth of American health care is that, while most people only use the emergency room for legitimate medical emergencies, many also use it for the same reason they use fast food drive-thrus and video-on-demand — it’s convenient. Despite their considerable expense, emergency rooms will treat anyone who walks through the door, require no appointments, and are open 24 hours a day, something of great importance to those who are either unwilling or unable to seek primary care during normal business hours. Since Medicaid enrollees share no cost burden for their medical care, they also have no incentive to seek that care in a less costly setting.

While that’s true, it’s not a surprise, More emergency room use isn’t necessarily bad.

I’ve written about the OHIE so many times, I’m not wasting time praising it. Let me say that I have no problem believing these results. Unlike many others, I’ve never really believed that increasing insurance coverage leads to less ED use.  There are tons of reasons people use the ED over primary care. (See a 2010 post here http://theincidentaleconomist.com/wordpress/when-the-emergency-room-is-your-only-option/).

Improved access will lead to, well, increased access. Emergency room care was never free, no matter what people heard in the media. Telling people that they can NOW go to the emergency room with coverage should lead to MORE people going to the emergency room. Increased access does not always mean decreased spending and more primary care.

Moreover, until someone proves to me that the increased ED use was unnecessary, I don’t know why anyone would assume it’s a bad thing. If our goal is to increase people’s access to the health care system, getting more people insurance (like Medicaid) is a good tool for that. If our goal is to help people make more effective use of the healthcare system, increasing coverage isn’t necessarily going to be as good a tool.

The goal of Obamacare is to help people, and that’s what’s always scared the right wing ideologues.  If people again see that the government can actually help people they’re ideology is doomed.

There was also good news in the study which Paul Krugman pointed out, Medicaid Nonsense.

Busy day, no additional blogging until much later. But you should be reading The Incidental Economist on the Oregon Medicaid study that’s creating a lot of fuss today. Basically, budget woes forced Oregon to allocate Medicaid access by lottery, giving a rare randomized experiment. Those who got Medicaid suffered much less financial distress and less depression; they received more preventive care; but on some (not all dimensions) their health wasn’t significantly better than those who lost out in the lottery.

Somehow, conservatives think this is a big win for their opposition to universal health insurance. Why? What it suggests is that the health benefits of ANY kind of health insurance are somewhat hard to identify over a two year period; so, are you about to give up your own insurance, or is your best bet that having that insurance is still a very good idea? And the financial benefits are a big part of that! Since you are going to treat your illnesses, better not to bankrupt yourself in the process, right?

Oh, and until now the claim of right-wingers has been that Medicaid actually makes you sicker; serious researchers have always said that this was a case of selection bias, because sicker people got Medicaid — and now we have confirmation: those who got Medicaid were at least somewhat healthier than those who didn’t.

Above all, you should bear in mind that if health insurance is a good idea — and you are nuts if you let this study persuade you otherwise — Medicaid is cheaper than private insurance. So where is the downside?

And Ezra Klein had this to say about the study, Here’s what the Oregon Medicaid study really said.

Here’s what we can say with certainty: Medicaid works as health insurance.

That might seem obvious. It’s actually not. A big criticism of Medicaid is that it pays doctors so little that it’s essentially worthless because no doctor will see you. But the Oregon residents who won the Medicaid lottery got much more health care — including preventive health care — than the residents who lost it. They also saw catastrophic health costs basically vanish.

[…]

The problem with the Oregon study is that it doesn’t help us figure out how to make health care or health insurance better. We don’t know if the results speak to the health care you get through all health insurance or just Medicaid or if they’re just an artifact of the study’s timeframe and sample size. We don’t know if different ways of designing insurance programs would lead to radically different care outcomes (we actually tried a randomized study on that question in the 70s, and the answer, at least then, was “not really”). And so we don’t know whether we’re seeing a problem in Medicaid, an inconvenient truth about medical care, or something else. Worse, we don’t know what to do next.

But we could find out. Studies like this one don’t need to be so rare. The government could put a very small amount of money — say, one percent of the federal budget — toward designing and conducting them across all areas of public policy and the results would help us spend the rest of our dollars much more wisely. There’s no reason the Oregon experiment has to be a unicorn.

I think that’s a great point, we need more studies to see how things are actually working.  No one thinks Obamacare is perfect, and as most government programs, will be changed going forward.  All the ideologues have been calling it a failure since it passed. That Schwertner and the like would discount the good news in the study – of how people are actually being helped – and overly focus on the negative is not surprising. That’s what they do when they’re trying to justify cruelty.