How the Liberal Press is Spinning the Oregon Medicaid Study

As Peter Suderman reported yesterday, The New England Journal of Medicine released a study on Oregon's Medicaid program — and it has sent liberal supporters of ObamaCare into a tailspin. The study is significant because its sample size is both random and large and therefore its findings are a decent first, though not conclusive, indication of what Medicaid will — or, rather, won't — accomplish if ObamaCare succeeds in pumping gazillions of dollars more into the program to achieve its goal of universal coverage. Bear in mind that the main point of offering coverage to America's 40 to 50 million uninsured is to improve health and save lives.

The study compares the health outcomes of more than 12,000 able-bodied uninsured adults below 100 percent of the poverty line, about half of whom were randomly enrolled in Medicaid and about half of whom were not. This kind of random assignment is as close to a lab-style controlled experiment as one can conduct in real life because it controls for variables such as race, income and health status, isolating the impact of the program.

Here's how it summarized its own core findings:

Approximately 2 years after the lottery, we obtained data from 6387 adults who were randomly selected to be able to apply for Medicaid coverage and 5842 adults who were not selected. Measures included blood-pressure, cholesterol, and glycated hemoglobin levels; screening for depression; medication inventories; and self-reported diagnoses, health status, health care utilization, and out-of-pocket spending for such services.

We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels [a marker for diabetes] or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (?9.15 percentage points; 95% confidence interval, ?16.70 to ?1.60; P=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.

This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.

(Emphasis added.)

And how are liberal pundits reporting its findings? Take a look at a not-so-random sampling of their headlines and excerpts.

 The New Republic's Jonathan Cohn:

 The New Study that Republicans Who Reject Medicaid Must Read

A report indicates just how important it can be in improving poor people's lives

The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses…

The other big finding was that people on Medicaid ended up with significantly better mental health: The rate of depression among Medicaid beneficiaries was 30 percent lower than the rate of depression among people who remained uninsured. That's not just good health policy. That's good fiscal policy, given the enormous costs that mental health problems impose on society—by reducing productivity, increasing the incidence of violence and self-destructive behavior, and so on…

But one place improvement did not appear was physical health. And this was something of a surprise…

Mother Jones, Kevin Drum

Followup: Medicaid Probably Does Improve Health Outcomes After All

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…

Bottom line: Access to Medicaid probably did improve health outcomes. It's just that the study was too small to say that with certainty.

(Emphasis original.)

The Washington Post, Sarah Kliff

Study: Medicaid reduces financial hardship, doesn't quickly improve physical health

As heated fights over the health law's Medicaid expansion engulf state legislatures, a sweeping new study indicates that the program is unlikely to quickly improve enrollees' physical health.

The research, published Wednesday in the New England Journal of Medicine, did find that low-income people who recently gained Medicaid coverage in Oregon used more health-care services.

New Medicaid enrollees had less trouble paying their bills and saw significant improvements in mental health outcomes, with rates of depression falling by 30 percent.

But on a simple set of health measures, including cholesterol and blood pressure levels, the new Medicaid enrollees looked no different than a separate group, who applied for the benefit but were not selected in a lottery.

The Incidental Economist, Aaron Carroll and Austin Frakt 

Oregon and Medicaid and Evidence and CHILL, PEOPLE!

First of all, we're somewhat annoyed that the NEJM sent out press releases and the study to journalists, but not people like us, because we now have to rebut the gazillion stories that have already been written on a study I just found out about an hour ago. Maybe they should let some knowledgeable people see it early, too. Or just wait until it goes live to tell everyone. But we digress. Let's get into it.

Early results showed some promising evidence that Medicaid improved process measures, self-reported health, and enhanced financial protection. This update, at 2 years, was intended to give us some harder outcomes. The results are "mixed"…

 The New York Times, Annie Lowrey

Medicaid Access Increases Use of Care, Study Finds

It found that those who gained Medicaid coverage spent more on health care, making more visits to doctors and trips to the hospital. But the study suggests that Medicaid coverage did not make those adults much healthier, at least within the two-year time frame of the research, judging by their blood pressure, blood sugar and other measures. It did, however, substantially reduce the incidence of depression, and it made them vastly more financially secure.

Readers are invited to read the original articles and give their own Pinocchio rating with "zero" indicating most honest and "five" most dishonest.

One thing to note, this study is consistent with scores of others as Avik Roy notes here showing that Medicaid produces no appreciable physical health gains for its beneficiaries compared to those without insurance.

Update: Ezra Klein's old post was erroneously included in the sample.

Update II: I'll keep updating new headlines and stories about the study as they keep filtering in. Here's one now:

Associated Press, Ricardo Alonso-Zaldivar 

Medicaid Improved Mental Health for Uninsured

If you're uninsured, getting on Medicaid clearly improves your mental health, but it doesn't seem to make much difference in physical conditions such as high blood pressure.

The counterintuitive findings by researchers at Harvard and MIT, from an experiment involving low-income, able-bodied Oregonians, appear in Thursday's New England Journal of Medicine. The study offers a twist for states weighing a major Medicaid expansion under President Barack Obama's health care law, to serve a similar population of adults around the country…

It also debunks a widespread perception that having Medicaid is no better, and maybe even worse, than being uninsured.

Comments

[some guy]

As Irish said last night, Medicaid is just a cost redistributing placebo. Just having it makes people less depressed. Otherwise, there are no significant effects... other than all the "other peoples' money" that gets wasted.

[some guy]

And all these articles are focused on the either the placebo effect or the redistribution effect. Yes, Medicaid is good at forcing a lot productive people to pay lots of money so that a few poor people won't go bankrupt when they have a catastrophic illness or injury. I don't think anyone really debates that point.

[VG Zaytsev]

What does 'going bankrupt' even mean to a poor person - other than being a windfall.

[KDN]

"Why you beggin me for money? You ain't broke, you're even."

[Some call me Tim?]

Exactly. A poor person receiving $50-100k in emergency care is something that the hospital will ultimately have to write off, it's never going to be repaid. They can chase that person down for the rest of their lives...wont matter.

[Another David]

If Medicaid patients are more likely to be diagnosed with and treated for diabetes, but no more likely to see their diabetes symptoms improve, WTF is going on with that "treatment"?

[some guy]

Life decisions, dude. It's like the woman who goes to the ER over 50 times a year because she's too lazy to take her insulin. She has insulin. She knows how to use it. She just doesn't fucking feel like it. (Seriously, this woman exists. I forget where I read about her, though.)

[Another David]

I don't doubt she does, but a few people being that lazy/stupid is one thing - so many of them that the needle doesn't budget at all? Nobody is using the meds properly? That needs some follow-up.

[Another David]

Budge. Goddamn, I suck at typing.

[NoVAHockey]

i believe it. just based on my anecdotal EMT experience. hell, i'm basically on a first name basis with this one guy who refuses to treat his diabetes.

[some guy]

Some people just refuse to take care of themselves, no matter the consequences. No amount of insurance is going to help them. It's just going to raise costs.

[NoVAHockey]

yep. instead of just carting this guy to the ER ever few weeks and eat the cost, we pay to have him enrolled in a program. and then we cart him to the ER every few weeks and the insurer, who is paid by the taxpayer pays.

[sarcasmic]

Someone who is too lazy to take steps in their life to increase their income so they will not need Medicaid is probably too lazy to follow the orders given by the doctor they see with Medicaid.

[WTF]

I'm pretty sure that's victim-blaming, or othering, or racism, or something that helps lefties avoid addressing any actual arguments.

[Another David]

I'm pretty sure saying "poor people are only poor because they're lazy" is some brand of fucking retarded, yes.

[sarcasmic]

I'm pretty sure that when someone argues against a statement with the word "only" in it that they're setting up a straw man.

[Another David]

If you're not setting up "too lazy to get a real job" as the default for Medicaid qualifiers, then I'm not sure how to parse it so it still relates to the question.

[sarcasmic]

I never said anything about "default" either.

Just that if someone is on Medicaid because they're too lazy to better themselves, they're probably too lazy to follow a doctor's instructions.

Nothing in that statement says that all who are on Medicaid are lazy, or that by default if someone is on Medicaid that they're lazy. It's almost as if I offended you personally. Is that because you're lazy?

[Another David]

Were you too lazy to read the part where the disconnect between treatment and symptoms was study-wide, not limited to a few outliers? "A few people are lazy" is a really dumb answer to "why doesn't diabetes medicine seem to work for anybody in this group?"

[sarcasmic]

"why doesn't diabetes medicine seem to work for anybody in this group?"

Here's a hint: the medicine works just fine if it is used properly.

[LTC(ret) John]

Is that Sugarfree bait?

[BuSab Agent]

My younger brother was exactly like this woman. He died of an aneurism at age 37. His room was chock full of unused diabetes meds.

[wareagle]

media fudges facts; Shikha surprised?

[VG Zaytsev]

She's probably surprised that everyone else does it too.

[LTC(ret) John]

She is branching out, for the first time in a while, from her pet cause. Takes a while to notice other things again.

[darius404]

First time in a while? Unless "a while" means "1 month".

[gaijin]

The truth, whatever it is, matters not...the country is a tower of babble chattering it's own reality into existence through the language of tribal political affiliation.

[gaijin]

*realities

[Austrian Anarchy]

You can lead the left to facts, but you can't make them think.

[Night Elf Mohawk]

Compared with the uninsured group, those in the Medicaid sample got 30 percent more hospital care, 35 percent more outpatient care and 15 percent more prescription-drug care. There were similar gains for preventive care; mammograms were up 60 percent and cholesterol monitoring rose 20 percent.

And, yet, they weren't physically healthier.

[LynchPin1477]

That doesn't surprise me all that much. Look at the health indicators they tracked: hypertension, high cholesterol, livediabetes. All are strongly correlated with obesity. Going to the hospital more and taking more drugs isn't going to make you thin unless you're jogging to the ER.

[Raston Bot]

So instead of taking Prozac?, folks should just go on Medicaid for their depression. Got it. Lesson learned.

[$park?]

The real lesson is that neither Prozac nor Medicaid will make the world suck less.

[LynchPin1477]

So the rate of catastrophic expenditures dropped from an already fairly small 5.5% to 1%. Explain to me how a simple voucher system for the poor that actually then allowed people to take advantage of free market forces wouldn't accomplish the same thing, and at probably a much, much lower cost since it would be easier to administer? And with a freer market the costs of medical procedures would like fall, at least in some areas, thus reducing the risk of catastrophic expenses.

[Jordan]

No we need more central planning and $60 trillion in unfunded liabilities!

[LynchPin1477]

I also hate the way the drop in depression incidence is reported. If I'm interpreting everything correctly, the rate of depression fell 9.15% compared to the control group. This is reported as a 30% decline, so I *think* that depression rates must have been close to 30% in the control group and closer to 21% in the Medicaid group. 21% is still pretty high. One might argue that for the cost, the improvement should be greater. But it sounds a lot more impressive to say 30% decline.

[ThomasD]

Given that the response rate for most typical antidepressant agents is - at best - around 40%, it would be extremely surprising to see anything even close, much less higher (which would be a major warning flag.)

BTW those reported response rates are from studies with monitored therapy. Out in the general population you would also have to factor in non-compliance. So a 0 response rate is -comparatively speaking- surprisingly good.

Given the population I'd have expected something more in the 10-20% range.

[LynchPin1477]

You seem pretty knowledgeable about this stuff so let me ask if the "depression" reported here was long-term, clinical depression (the kind where you get depressed even when things are relatively good) or short-term, I'm depressed because things suck, depression?

[ThomasD]

Maybe. Depression and anxiety may be normal reaction to stressful or difficult life events (car wreck, death in the family, job loss, etc.)

Roughly speaking the condition becomes clinical when it persists and adversely affects the other parts of your life that haven't already gone to shit.

There is a chicken/egg problem of which came first, the depression or the life crash. But practically speaking this question can rarely, if ever be resolved so current treatment approaches (medications and/or cognitive-behavioral techniques) are employed on most anyone who qualifies for a diagnosis of depression.

[ThomasD]

The diabetes related results should be completely unsurprising to anyone who has dealt with, or managed diabetic patients.

Detection and treatment are all well and good, but if the patient is unwilling or unable to modify their own behaviors (mainly alter their diet and increase physical activity) then medications often prove ineffective at substantially improving HgbA1c scores.

While every individual situation may be unique, as a cohort the public assistance population is one that has already demonstrated an unwillingness or inability to successfully modify their behaviors when faced with negative consequences, else many would not need such assistance.

So by selecting out diabetics from a medicaid program you have already skewed the patient population towards treatment failure.

[LynchPin1477]

The Mother Jones article is a pile of BS. All of the 95% confidence intervals are consistent with no change, and admit the possibility of worse or better health outcomes. Yes, the median (I presume) values show slight improvement, but that means nothing given the size of the uncertainty.

The phrase "Possibly positive but inconclusive" is absolutely meaningless. Inconclusive means inconclusive. And the headline "Medicaid Probably Does Improve Health Outcomes After All" is just dishonest, pure and simple. An honest headline would be "Possibly positive, possibly negative, we can't tell, because that is what inconclusive means. All we can say is that any change between the two groups was too small to detect in a sample size of 12,000."

[ThomasD]

Yes, this is heart of the matter.

We spent billions and have nothing significantly positive to show for it.

[LynchPin1477]

Comment from the Mother Jones article:

We have apparently degenerated mentally to the point that a positive result of providing preventative health careto human beings requires verification from a study.

Did I honestly just read this?? Is someone actually saying that empirical research and evidence-based reasoning is a sign of mental degeneracy??

[ThomasD]

When it comes to doing whatever it is that the hive-mind wants to do then yes, and shut up as well.

[LynchPin1477]

Another good one:

All three outcomes had the expected sign. Probability of this happening by chance is 12.5%. For me that's enough to say "probably does improve health outcomes," especially given my prior belief that there would be at least SOME improvement.

That said, the effects seem kind of small to me.

Assuming his analysis is correct, 12.5% happening by chance isn't all that significant, at least in my field. We wouldn't even call that a 2-sigma result. 3-sigma (

[LynchPin1477]

D'oh. Was going to say 3-sigma is usually needed to claim a believable detection (

[Spartacus]

Sounds like somebody is just assuming a 50-50 chance of positive or negative, and then assuming independence. 0.5^3=0.125.

[Some call me Tim?]

This reminds me of people who think all outcomes are 50-50.

Something either happens or it wont, so it's a 50-50 shot.

[Somalian Road Corporation]

This person probably had unkind words to say about Bush-era "faith-based initiatives" and is incapable of seeing the parallel.

[VG Zaytsev]

Here's a crazy interpretaion.

Health Insurance, including medicaid, is a financial product, period. So in this study, medicaid did in fact work in that it improved the financial position of the poor.

And it has very little effect on long term outcomes because people will seek medical care when they need it. Pre-paid healthcare schemes, aka health insurance, incentivize overuse of healthcare services because their use or lose it nature, combined with minimal marginal costs to users.

Whatever mythical benefits arise from preventative care are balanced to some degree by iatrogenic problems.

And insecurity can be a factor in mild depression, so the program reduces depression by reducing financial insecurity.

It would be interesting to do a similar study of people with and without employer provided health insurance. I bet it would produce similar results.

[Lord Humungus]

pretty much - I went ten years without seeing a doctor. I only recently went to take care of a medical issue that wasn't curing itself quickly enough.

[Night Elf Mohawk]

Health Insurance, including medicaid, is a financial product, period.

I don't think that's a crazy interpretation. I have health insurance to cover the cost if something really bad happens. I budget for office visits, getting the cold, breaking a bone, etc.

[LynchPin1477]

I'd say it is exactly the right interpretation of what health insurance should be. The point of any insurance is to help you cover the financial cost of low-probability but high-risk events. It might be worth the money to insurance agencies to discount preventative care and incentivize healthy living as a way of reducing the probability of a problem, but that is sort of a second order effect.

[Two Fingers]

With a high degree of certaintly, I can say that Kevin Drum is a statistical idiot.

The NEJM results don't show that Medicaid 'most likely' had an effect. Even if the p-values indicated a statistically significant effect in the objective health measures (which is not even close to true), the clinical effect of the difference in those measures was inconsequential.

Bottom line: Access to Medicaid probably did NOT improve health outcomes.

[ThomasD]

Exactly, and if Drum and the others were truly concerned about helping the poor they'd be aghast at the lack of tangible improvements.

Even if one starts from a desire to throw massive piles of loot at the problem, at this point they should be willing to concede that current practices are not working. And if they are serious about achieving positive outcomes they should be open to exploring alternative approaches.

The apparent desire to paper over the wasteful and ineffective realities speaks more to protecting an entrenched government-industrial complex than to actually helping the less fortunate.

[The Late P Brooks]

Medicaid Access Increases Use of Care, Study Finds

Now, there was a government grant well spent.

[Don Mynack]

Does Medicaid make them more productive people? Does it lead to them eventually getting off Medicaid and getting their collective crap together? Or does it lead to the culture of dependency that the lefties seem to covet more than anything? The only goal of any of these programs should be to leave fewer poor people than were there before. Anything else should be considered failure.

The fact that our "children's health program" is getting clogged up with more even more deadbeat adults, who seem to refuse to better themselves, is not something to be celebrated.

Just write them checks already and be done with it.

[ant1sthenes]

Next anti-welfare shocker: "EBT users report being spending less (of their own money) on food and feel less depressed, but their eating habits were about the same".

Yes, this study probably indicates that (at least for heavily lifestyle-based indicators, which doesn't say much), Medicare is more of a convenience than a need for many people who are eligible, relieving them of the need to make sacrifices and hard decisions in order to provide for the basics.

That's rhetorically useless, since only people who are already skeptical of welfare are going to be persuaded. There's a whole class of people who consider it an injustice to have to prioritize or sacrifice wants to pay for needs.

[Tony]

Then there are those who consider it an injustice to have their income taxes hiked 4% even though they already have access to every need and want in the world.

Explain to me this: why are poor people motivated by taking stuff away from them, but rich people are motivated by giving them stuff?

[LynchPin1477]

When you take something away from someone that they earned in exchange for productive work, it discourages that productive work. This is especially true if what is taken isn't used to produce any benefit for the person it was taken from. Rich or poor, it doesn't matter.

When you give something to someone in exchange for productive work, it encourages that productive work. Rich or poor, it doesn't matter.

When you give something to someone without any regard for productive work, it encourages the behavior that made them eligible for that in the first place. Rich or poor, it doesn't matter.

[Tony]

It does matter. People do not aspire to be poor so that they can receive government benefits. They'd much rather be well off. As proof of this claim, I present the complete lack of wealthy people clamoring to be poor so they can live the good life.

Empirical reality contradicts the claim that taking any amount in taxes discourages productive work--we've had tax rates at much higher levels, and nobody ever stopped trying to succeed and become rich.

Maybe they had to work a little harder for less of a bonanza, but so what? It's absurd to claim that upper-end incomes have any relationship with the work in or productivity out at this point. At best you can claim that there is a point at which taxation becomes discouraging, but you can't claim we're always at that point.

[LynchPin1477]

I suspect you are right in that most people don't aspire to be poor. But to say that they'd much rather be well off? Well, how much more well off? If they wanted to be really rich they'd be doing more to at least try to make that happen. Would they succeed in becoming wildly rich? In most cases probably not, but they could probably succeed in become better off than they are on government benefits. A lot of people don't do that because the marginal benefit isn't worth the effort. In other words, they may not be as well off as they'd like to be, but they are well off enough. And of course there are exceptions to this.

As for taxes vs work, I suspect that there is much more a sliding scale. Again, it is about marginal gain for the extra effort. The lower the marginal gain, the less likely someone is to put in the effort. I don't think we should have zero taxes -- I'm not an anarchist and I think there is plenty of good stuff that government can and should do. But I do think taxes should be no higher than necessary to achieve those ends, and that those ends can be pretty well defined and limited.

[LynchPin1477]

It's absurd to claim that upper-end incomes have any relationship with the work in or productivity out at this point.

I claim that upper-end incomes have a relationship with the work in and productivity out that someone values, excepting the rampant cronyism in lots of the private sector. I may not value that work and productivity as highly, but I also don't care. If someone can convince someone else that their skills are worth $20 million/year, who am I to argue? It isn't me that's paying them. More to the point, what right do I have to tell them that they can't make that much money? Again, cronyism excepted.

[KPres]

"Empirical reality contradicts the claim that taking any amount in taxes discourages productive work--we've had tax rates at much higher levels, and nobody ever stopped trying to succeed and become rich."

Uh...the the data shows exactly that they did. The government collected essentially no revenue from the 90% marginal rate, for example. Obviously that's because once a person reached that threshold, they had no incentive to earn more income so they didn't.

[ant1sthenes]

"People do not aspire to be poor so that they can receive government benefits."

That's irrelevant. The question isn't whether a person with a GED and poor impulse control will become a millionaire with a little effort, it's whether he can be self-sufficient without the government propping him up. If people with Down's Syndrome can provide for themselves, Democrats probably can too. Their IQ isn't usually that much lower.

But, if the pay for working an extra hour and not working an extra are the same, you might as well not work, whether that's because you're poor or rich.

There's an increasing cost to your personal life to each hour you work, and dropping your pay shifts that to the left. A tax increase (assuming your pay is directly or indirectly tied to how much you work) is going to do the same thing.

[Tony]

I don't know what large-scale physical health outcome changes among able-bodied people you can expect after two years, but the point of Medicaid is arguably more about reducing financial risk than improving health outcomes. That's a complex issue, the concern of cultural habits and medical science. To put it in terms of capitalism, as in what's supposed to be virtuous about it (hard work, ingenuity, and risk-taking lead to success), the program eliminates the risk of a catastrophic financial hit to people who can use the gained security to go be productive.

I realize you guys think there's something fundamentally different about poor people's brains that makes them extra motivated by catastrophe and the threat of inescapable poverty (whereas rich people, completely oppositely, are motivated to be productive when they're given more tax breaks).

[LynchPin1477]

IIRC correctly, this study was specifically looking at health indicators that should show improvement over the short term, assuming they were being implemented properly. Your point about financial risk vs health outcomes is a good one that was pointed out above, but Medicaid and the health care law were sold as being about much more than simple insurance against catastrophe. If that was the only goal, then there are much simpler and probably much cheaper ways of doing so.

As I said above, nearly all people are motivated to avoid catastrophe when they actually have to face the risks associated with it. An nearly all people are motivated to be more productive when they can more fully enjoy the benefits that come with that. And nearly all people would choose to enjoy the benefits of being productive without actually having to be productive if given that choice.

[Tony]

But people can't decide to avoid healthcare catastrophes... All Medicaid is doing is eliminating that one financial risk from the mix, thus making capitalism more fair (according to the terms used to defend it as a good thing) and more productive. There's motivation to be productive and then there's ability. Being bankrupted by medical expenses means you have no ability to invest in anything else, assuming you get treatment and aren't made even less productive by the medical condition itself.

Your point is taken about short-term health gains that should have been demonstrated, but I want to see a comparison to private insurance. It's basically equivalent--people on private insurance are not significantly differently burdened from people on Medicaid, but they similarly get the risk mitigation. Are their motivations too being distorted in a way that reduces productivity?

[LynchPin1477]

But people can't decide to avoid healthcare catastrophes

But in some cases they can choose to mitigate or increase their risks. Ideally, when people put themselves at higher risk the costs of insurance go up, thus providing an incentive to live healthier.

All Medicaid is doing is eliminating that one financial risk from the mix, thus making capitalism more fair

Except I don't think that is all Medicaid is doing. It is trying to control the kind of care people get, what they pay for it, etc. There are simpler, and I think better, ways to just help people pay for insurance. Also, I'm not sure what terms you are referring to that defend capitalism.

Are their motivations too being distorted in a way that reduces productivity?

I'd also like to see a comparison. I could see health outcomes being similar since, again, it is more about lifestyle than jut having insurance. But I could also outcomes being better because when someone is paying with their own money, they have more of an incentive to reduce their costs (be healthier).

[Adam330]

"he point of Medicaid is arguably more about reducing financial risk than improving health outcomes."

Bull. The Medicaid expansion was sold as providing "access" to healthcare for the poor. But this study shows that the poor have access to healthcare. Any additional access that Medicaid provides is only to unnecessary and/or ineffective care.

But now that you've conceded that Medicaid should only be about reducing catastrophic financial risk, I'm sure you'll agree that it would be much better structured a high deductible/catastrophic only plan rather than as first dollar coverage. Right?

[Adam330]

Also, would you care to explain why you've changed you're position 180 degrees?

http://reason.com/blog/2011/07.....al#comment

Tony| 7.8.11 @ 4:24PM |#

Tman hits the nail on the head. Of course greater access to healthcare insurance means better health.

[Some call me Tim?]

This is what happens when you engage a sockpuppet and actually make it explain previous statements...silence.

[The Late P Brooks]

People do not aspire to be poor so that they can receive government benefits.

No, they don't "aspire" to be poor. They may, in fact, aspire to be rich(er). However, once they have become entangled in your precious social safety net, they find that working more or harder actually results in a net loss of income as they hit income levels which result in loss of eligibility for government assistance. Now, I do not doubt for an instant that your solution is to make those programs irrevocable, but that's not gonna fly.

Fucking incentives- how do they work?

[Tony]

Obviously any such phenomenon is a flaw in the system, and it may happen sometimes here but it is not the overwhelming reality of safety net programs.

My question is simply why poor people are motivated by the threat of starvation while rich people are motivated by being given more money.

[KPres]

You're a fucking moron.

Just wanted to get that out of the way.

The difference, obvious to everybody with an triple-digit IQ, is that the income a poor person receives from welfare redistribution is in no way tied to his positive productivity, so his rational choice is to stop working while still receiving the income. The benefit of a tax break for the wealthy person, OTOH, is a direct function of his productivity. If he stops producing, his benefit from the tax break is zero. And if he produces more, his benefit from the tax break increases proportionally.

I can't tell if you're really too stupid to understand this, or whether you're just deliberately obfuscating the way you normally do. Either way, people like you should have no voice or vote in any political function, and stripping you of that power is the single most important policy the rest of us should be pursuing.

[Some call me Tim?]

He thinks he's found some sort of witty way to pose a "conundrum" for those who disagree with statist welfare policies.

He clearly has no idea that his "insight" is not profound and simply shows a lack of understanding of how incentivization works.

[Ray Lyons]

Some points on research methodology: The original post uses the term "significant" to refer to sample selection and random assignment of subjects to study groups. In research design these two elements pertain to a study's "validity" more than to its "significance." The term significance has other connotations, the most common (and troublesome) of which is "statistical significance."

The results of statistical significance testing are Pass/Fail. There are no such things as shades or degrees of statistical significance. Being close to a 95% probability testing threshold is not good enough. (Think of the lottery player saying s/he was close to winning because s/he "had all but one of the numbers.")

The fact that data fail statistical significance testing (they are "statistically insignificant") is not proof that the difference/effect under study does not exist. Instead, the testing begins with the baseline assumption of the non-existence of this effect/difference, called the "null hypothesis," the ineffectiveness of Medicaid in this case.

It is logically impossible for a decision process based on a given assumption (the null hypothesis) to tell us how true or false this assumption is. So, the Oregon study does not in any way prove Medicaid to be ineffective. The hypothesis of Medicaid effectiveness, conceived as health outcomes, is said to be "unproven." "Unproven" does not mean "false."

[Some call me Tim?]

So what would it take for it to be proven "false"?

[Ray Lyons]

Statistical significance testing, when used with random sample selection, is is a way to guess whether what is seen in a sample is likely to match the entire population we're interested in. To avoid the weakness I described you would need to abandon the approach completely. And take a census of every Medicaid recipient and potential non-recipient(control group) nationwide and see if/how many had improved health measures. If none did, then the hypothesis is falsified. If you want to devise a hypothesis like "at least 10% of Medicaid recipients show improvement" your census would look for that level. (I'm presuming you randomly assigned all subjects nationwide to Medicaid and control groups.)

Since this is impossible, you can stick with the statistical testing technique by doing many repetitive studies like the Oregon study and always find the same results. Even with this you cannot technically PROVE ineffectiveness. But you can announce that it is reasonable to bet that your otherwise incomplete data do reflect the true state of affairs--meaning Medicaid is ineffective. Same thing as saying you've scanned the skies for 50 years without finding extra-terrestrial beings. You take your chances and finally conclude there's none to be found.

[Some call me Tim?]

So basically, this is step one of that process.

[Coeus]

Krugnuts is spinning it too.

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?

[PH2050]

...And now I don't feel bad about ducking taxes while donating to the X-Prize Foundation and other similar organizations.