By Katherine Baicker, Ph.D., Sarah L. Taubman, Sc.D., Heidi L. Allen, Ph.D., Mira Bernstein, Ph.D., Jonathan H. Gruber, Ph.D., Joseph P. Newhouse, Ph.D., Eric C. Schneider, M.D., Bill J. Wright, Ph.D., Alan M. Zaslavsky, Ph.D., and Amy N. Finkelstein, Ph.D. for the Oregon Health Study Group
The New England Journal of Medicine, May 2, 2013
Our study provides evidence of the effects of expanding Medicaid to low-income adults on the basis of a randomized design, which is rarely available in the evaluation of social insurance programs. We found that insurance led to increased access to and utilization of health care, substantial improvements in mental health, and reductions in financial strain, but we did not observe reductions in measured blood-pressure, cholesterol, or glycated hemoglobin levels.
http://www.nejm.org/doi/full/10.1056/NEJMsa1212321
And…
Protecting Finances and Improving Access to Care with Medicaid
By Richard Kronick, Ph.D., and Andrew B. Bindman, M.D.
Editorial, The New England Journal of Medicine, May 2, 2013
Insurance has three main purposes: to protect financial assets in the event of illness, to improve access to care, and to protect health.
First, Baicker and colleagues found that insurance provided a low-income population with considerable financial protection.
Second, Medicaid was associated with dramatically improved access to care.
It is less clear how well Medicaid accomplished the third goal — improving health.
The minimal effects of Medicaid coverage on measures of physical health are not entirely surprising given the many steps needed between the availability of insurance coverage and the delivery of appropriate care. In addition, the short follow-up period of the study, the small number of persons with chronic conditions in the study sample, and the limited number of outcomes may have contributed to a false negative result. This study did not or could not address many important potential health benefits of health insurance, including early detection of cancer, a reduction in sick days from school or work, and a reduction in mortality.
http://www.nejm.org/doi/full/10.1056/NEJMe1302107
The Oregon Health Insurance Experiment (A concise summary of findings): http://www.nber.org/oregon/
Comment:
By Don McCanne, M.D.
The Oregon Experiment unequivocally demonstrates that Medicaid improves access to care and provides considerable financial protection for the low-income population that it serves. Although it was not powered to demonstrate statistically significant improvements in health outcomes, a multitude of other research studies have already confirmed that the health-care interventions studied here are clinically effective.
Today there is a barrage of responses from conservatives and libertarians attacking Medicaid because this study supposedly shows that Medicaid had no significant effect on health outcomes. Thus they challenge the wisdom of implementing the Affordable Care Act provision that would greatly expand the Medicaid program.
Although there are many reasons to consider better options to Medicaid (e.g. single payer), withholding access to and affordability of care that has already been proven to be effective is certainly not one of them.
Perhaps the most significant set of observations in this study is the reduction in financial barriers to care. Most importantly, catastrophic expenditures (over 30 percent of household income) were reduced from 5.5 percent in the uninsured group to 1.0 percent in the Medicaid group. Those with medical debt were reduced from 57 percent to 44 percent, and those who had to borrow money to pay medical bills, or simply walked away from the bills, were reduced from 24 percent to 10 percent.
These reductions in financial barriers improve access which, in turn, improves health outcomes, although these numbers are still not good enough. With a well-designed single payer system, we could do much better.