Would anyone care to take up Megan McArdle’s gauntlet, thrown down at Bloomberg View, at to whether the Affordable Care Act has been a net gain?
There’s a new paper out looking at how the Affordable Care Act has transformed health-care access, and in turn, what that has done for health. The authors’ first answer probably won’t surprise you: when millions more people became insured, more got checkups and primary care doctors. But it’s not obvious that these people got any healthier. As the paper puts it: “No statistically significant effects on risky behaviors or self-assessed health emerge for the full sample.â€
Other studies have found substantial effects on self-assessed health, but on the harder markers of health — like blood sugar, cholesterol and blood pressure — the famous Oregon Medicaid Study found no significant improvement when government gave people health care.
It turns out the link between “health care†and “health†is not as close as we would like. Health insurance is not magic. Insurance can give you access to a doctor, but it cannot make you take your medicine. An absolutely astonishing percentage of people don’t take their hypertension medication, even though the side effects are minimal, the medications are cheap generics, and the benefits are large; overall, about 50 percent of patients seem to fail to take their medicine as recommended. Insurance cannot make you stop drinking or smoking or overeating. Just ask the primary-care physicians charged with bullying people out of those behaviors. Yes, people with health insurance are more likely to be healthy. But people with good health insurance are also more likely to be successful folks who are remuneratively employed, which seems to be independently correlated with health, even when everyone is getting their health care through Britain’s National Health Service.
Even as some people use health insurance to get their blood pressure down or their lung disease treated, others will fail to comply with treatment regimens, or will get treatments that turn out in hindsight to have been a bad idea, or will spend money on unhealthy things now that they’re spending less on health care. Which effect ends up being larger in aggregate is an empirical question, even though individuals may be able to point to a very clear benefit or detriment to themselves.
That empirical answer ends up being … kind of cloudy. Some studies show large health benefits from health insurance, others little, none, or even negative effects.
Politically, it doesn’t matter whether it’s a net gain. It benefits some people and they’ll defend it to the death as will those who like the PPACA for political reasons.
My own concerns about the PPACA had nothing to do with whether it was a net gain or not but that it did little to address the issues we need to resolve so desperately or even sets the stage for addressing them in the future.
But back to her question. Make your case that the Affordable Care Act was a net gain or a net loss.
Provide me with a metric for fear and I’ll make the case.
Insurance is about fear. Lack of insurance creates fear, insurance reduces fear. Lessen fear over health-induced bankruptcy and people can focus on the next set of worries to come popping up from the great Pez Dispense o’ Fear: their kid’s education, their elderly parents, their employment prospects, retirement.
People think poverty creates envy. It does, but that is not the dominant emotion. Poor people know that a health problem can cause them to miss work, lose pay, even lose their jobs. They know they are a broken leg away from a quick slide down the ladder into more despair. They are afraid. Health insurance removes one fear – they may get sick, they may lose work, but at the end of it they won’t be looking at a hospital bill that is half their annual income.
I guess it depends on the metric. Like you, I think it’s largely pointless as the ACA put a band aid on one issue and that’s about it.
It might be interesting to revisit all the promises about how the ACA would not only pay for itself, but also reduce the deficit.
She already answered the question: some people got healthier. Pretty sure there was no significant issue with people getting sicker after receiving access to a doctor.
– Kids can stay on their parents health insurance until 26.
– No lifetime maximums.
– 85% of premiums go to benefits
– junk policies that don’t cover anything are gone
There are lots of things ACA hasn’t solved, but the above are all big improvements. What has it made worse?
One thing conservatives always know: Health Care Doesn’t Work.
Always. Always. Always. It doesn’t work. It doesn’t make anyone better. It doesn’t help. It doesn’t do anything good at all for anyone. It’s always a waste of money.
This comes up every damned time conservatives start talking about other peoples’ health care. For themselves of course … diets are a very big issue, vaccination may be a no-no, maybe their religion forbids blood transfusions and injections of drugs. So, broadly construed, there are important medical issues that conservatives understand. For themselves.
For other people however … no such luck. The percentage of people who recover from an illness without seeing a doctor is just as high as the percentage who recover after medical treatment. Doctors prescribe medicines without any real idea of whether they work. They prescribe EXPENSIVE medicines because the pharmaceutical companies send attractive female sales agents to them to extoll the virtues of their potions. People insist on talking medicines which doctors know will do no good, such as antibiotics for virus-related illnesses. People don’t take their medicines properly, at a regular time each time, and finishing off their full prescription. Pharmacists are often incompetent. Doctors are much too highly paid — and nurse practitioners at half their salary are just as effective. Nobody comes to a hospital ER when there’s a big football game on, which shows anyone claiming to be horribly sick really can tough it out. People are all different, no one really can predict what medicine works on anyone, or what the proper dose is, it’s all guess work.
Watch ’em. These arguments pop up constantly. And there is a grain of substance. To give an example, a lot of people take a child’s dose of aspirin (81 mg) each day, with the idea that it wards off strokes and heart attacks. Well perhaps, but it’s not a certainty. The basic notion is that such a regimen will prevent maybe one or two heart attacks a year in a group of a thousand elderly men (with no effect on the number of strokes) or a couple of strokes per year in a group of a thousand elderly women (with no effect on the number of heart attacks). I.e., a group of people which without aspirin might have say 20 heart attacks will have 18 or 19 if all of them take aspirin religiously. It can’t be predicted whom the be the person protected. It can’t be said that aspirin made heart attacks more survivable among those who survived them. But study after study shows aspirin has some benefit. To some folks that seems significant — I’ve been swallowing aspirin myself for 40 years and I haven’t had any heart attacks, or at least none noticeable enough to knock me off. To other people, particular conservatives taxed to pay for such “medicine” for the unemployed or indigent, the whole notion is silly, nothing but a crap shoot designed to make money for the drug sellers. This isn’t how medicine worked in The Good Old Days when doctors made house calls like they were supposed to and you could pay the bill with a couple of dead chickens! Socialism just ruined everything and turned honest men into crooks and persuaded lazy people to play act at being ill and we should just stop the silly nonsense right now, AM I RIGHT?
Keeping in mind that I’m not an opponent of the ACA, people in a third of all of the counties in the U. S. have no choice of carrier on the exchanges. Right now there’s only one county with no carriers. The trend has been for carriers to withdraw from the exchanges and if that goes on it’s possible that the exchanges would become irrelevant for many people without federal action.
Also, people who didn’t carry insurance prior to the ACA and are compelled by the law to do so, especially those ineligible for any subsidies, may consider themselves worse off.
There are some political gains. The ACA and its travails has made the idea of single-payer more palatable. And the late repeal and replace disaster has shown the House GOP to be even more a hillbilly roadshow of Marat-Sade than some of us suspected.
As I think I’ve mentioned before, I supported single-payer for thirty years. But that was then and this is now. Now health care is so expensive and so accustomed to price increases that it doesn’t make any difference who pays. As long as there’s no commitment to cost control, health care spending will just grow out of bounds, leaving economic carnage in the rest of the economy in its wake.
The usual retort is “look at all of those administrative costs!” Canada’s health care administrative costs are about 15% and ours are about 30%. That means that single-payer could give us a one-time single-payer dividend of around 15%. At the present rate of increase that would be eaten up in a couple of years.
What is needed is cost control and single-payer just isn’t enough any more.
If the measure as articulated by McArdle is whether Americans are healthier because of PPACA, the results are, not surprisingly, flat. Perhaps a slight net gain if you consider those with a health illness who benefited from the guaranteed-issue insurance they were able to obtain through the Exchange.
However, it is ludicrous to believe that PPACA would ever improve the overall health of Americans. PPACA is mostly about health coverage (i.e. payment for health care) even though it was touted as expanding access to health care. Coverage is not the same as access. PPACA did little to address the barriers to access beyond expanding coverage and thus did little to change how people receive (or don’t receive) health care services.
When managed care was evolving in the late 70’s and 80’s, one of the benefits offered in the promotion of HMOs was that savings in the cost of providing health care services would be used to pay for education and other preventative health programs for members. The theory was that as members became healthier, the costs of care and treatment would go down. Didn’t happen. You can lead a horse to water, but you can’t make it drink. Same with all of us. Health plans can educate and coach on the importance of taking medicine, monitoring blood pressure, losing weight – even entice us with discounted gym memberships and prizes. As the health plans found out, Americans are stubborn about changing their behaviors and there was no ‘net gain’ in the overall health of the managed care members as compared to everyone else.
We have already learned this does not work. Now, if we could exclude lung cancer coverage for smokers, limit hospital and cardiac intervention benefits for individuals who are obese and are not compliant with their treatment protocol for reducing blood pressure and cholesterol, people may begin to pay attention. I am not suggesting that such measures should be adopted. I would note that PPACA goes in the opposite direction – guaranteed issuance of a predetermined set of benefits regardless of your lifestyle.
” people in a third of all of the counties in the U. S. have no choice of carrier on the exchanges.”
Which I think puts us back to where we were before the ACA. Cant find the post I wrote on this long ago when I used to write and did a county by county analysis, but it is pretty close.
Steve