I thought this piece was relevant to things we just saw in class yesterday, and so closely follows the worksheet we saw in class yesterday. The following post is inspired by a newsletter I received today from "Tradeoffs", which is a podcast on U.S. healthcare policy. In their newsletter today, they talked about "The Conservative Case for Shrinking Medicaid: Less is More".
Before we get into the article, the idea of "less is more" is actually an interesting and powerful idea and something we should pay attention. It turns out that most of us (especially in policy) have a bias to "add" when trying to fix things or improve things: What should we do about "border security?" Send more people. What should we do about surveillance? Have more regulations, and so on. It's an easy default to always do more. However, the argument for doing less is something that is important to hear out. In fact, professors Adams and Converse and other colleagues have research on this and you can read an article on that that here. Here is a quote from that article.
"People systematically overlook opportunities to change the world through subtraction," Adams says of the research on subtraction neglect, published in the scientific journal Nature. When people automatically default to adding, they may be selecting suboptimal solutions without considering superior ones."
Great, so without hearing any details about what the conservative case has to make, we are open to hearing ideas that make things work better, even if it means "less".
In the newsletter, they talked to people you and I and others "voted" for (i.e. legislators) and asked them about the case for “less” Medicaid. The newsletter then summarizes those findings like this:
They didn't agree on everything, but a few common themes emerged that I think will help folks understand the conservative philosophy on Medicaid:
- Three big concerns about Medicaid came up repeatedly. The experts I spoke with argued that 1) Medicaid coverage does not make people healthier; 2) states are incentivized to increase Medicaid spending with no limit; and 3) many people now covered by Medicaid could get health insurance elsewhere.
Those are some interesting points. I - of course - would like y'all to focus on the first one: Medicaid does not make people healthier. We can go down the rabbit hole of research on this, to summarize there was some compelling evidence that some expansions from one state with good causal design did not significantly improve physical health, but it did reduce depression and improve self-reported health, and of course some people take that as no effects on health (there is also a discussion to have here because for some people mental health is not health? But we can’t address everything in this post). On the other hand, research with administrative data using data from a number of states and the most recent ACA Medicaid expansions was - to our surprise - actually able to detect mortality effects from these expansions. Here is the quote:
Individuals in expansion states experienced a 0.132 percentage point decline in annual mortality, a 9.4 percent reduction over the sample mean, as a result of the Medicaid expansions. The effect is driven by a reduction in disease-related deaths and grows over time.
Let me clarify, mortality is such an extreme outcome, that I wouldn't have put money we would find an effect there, and especially from the recent Medicaid expansions which mostly affected people in their 30-50s, which is not a population sensitive to mortality. So the fact that they found an almost 10% (!!) reduction in mortality, is pretty surprising.
In short, you could see why some people would be able to back part of their claim that "Medicaid doesn't improve health" with some credible research, and at the same time, most of the evidence also points the other way.
But let's take them at face value, and agree with their point: Medicaid does not improve health. Even if that were true, as we've learned in class, this is an odd outcome to focus on evaluating Medicaid and importantly, on deciding if we should do less Medicaid. As we've discussed in class, the goal of Medicaid and many other insurance programs is to mitigate financial risk, and its merit should be firstly based on that. Which by the way there is evidence from yours truly on this that points at the fact that Medicaid does a great job on mitigating financial risk.
Now, let's give everyone the benefit of the doubt, and maybe people are concentrating on the effects on health not because it's a sleight of hand, but because of the logic of "Well this is a health program, so really the whole point is to improve people's health".
I think that's a great point, but if you are going to evaluate a program based on if it helps improve people's health, then let's have a program that is designed to improve people's health. That's a bit of a very important crux in American health policy, we want people to be healthier or at least we say we want that, yet we don't design a fully fleshed out programs to get at that. If you think about insurance seriously, and healthcare, it is mostly focused about "reaction". You get sick, you go to the Dr, we pay for that, and insurance covers that. As opposed to "prevention". That's why, if we want to think about new programs that focus on health, I'm on board, but I'm less on board on evaluating programs by metrics that they are not designed to do. This was one of the key lessons of the measurement class, and hopefully you'll notice how such simple insights remain relevant in conversations happening today (and tomorrow) on policy making.