Data Points and Dogma

By now, if you read MSM or conservative web sites, you’ve probably heard that a new randomized study of Medicaid in Oregon (published yesterday in the New England Journal of Medicine) shows the program has no impact on the health of people receiving it, which, some say, means the program is a worthless waste of money, or that its expansion via Obamacare should be resisted.

Kevin Drum, who has been following this development closely, reports the results rather differently:

In a nutshell, Oregon held a lottery a few years ago in which some people received Medicaid coverage and others didn’t. Today’s study is a two-year followup, and the headline result is that “Medicaid coverage generated no significant improvements in measured physical health outcomes.” But it turns out that “significant” is doing a lot of heavy lifting here, and the headline is extremely misleading.

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.”

Although most of the chatter involves the impact (or lack thereof) of Medicaid coverage on this brief list of health indicators, there’s no controversy whatsoever over one positive impact, as noted by Aaron Carroll and Austin Frackt:

Financial hardship matters. Here Medicaid shined. It hugely reduced out of pocket spending, catastrophic expenditures, medical debt, and the need to borrow money or skip payments.

Along with the undisputed finding in Oregon that Medicaid coverage also boosted use of preventive services, that’s a pretty big deal, since two of the principal purposes of Medicaid are to help low-income folk pay for health services and make regular physician visits instead of showing up in the emergency room for uncompensated care once a condition has become acute.

I don’t know anyone, however liberal, who believes Medicaid is a perfect health insurance program; its balkanization among states with different coverage and eligibility levels, and different degrees of administrative competence, makes it difficult to generalize. But the idea that this very limited Oregon study justifies increased balkanization of Medicaid via a block grant or “state flexibility” (typically code for letting states dump large numbers of people from the program altogether) represents a total non sequitur. More studies are welcome, but if this is supposed to be the silver bullet “proving” Medicaid is useless, then clearly, a data point is being turned into dogma by those who have already made up their minds that poor people should be left to their own virtually non-existent resources, or should continue to show up in emergency rooms when their blood pressure or A1C levels are far out of control.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.