Wednesday, May 8, 2013

O-Aren't-You Glad For Insurance?

(From top left: Mysterious liquids, pharmacy certifications, the lab's "sink," and a tub filled with:
packs of antibiotics, a carton of cigarettes, and hangover pills, on the lab counter)

A rusty cleaver.  A faucet-less sink.  And colorful, new blister-packs of house-made hangover pills.  The herbal medicine lab was a fascinating mixture of tradition and innovation, of regulations and disorder.  In college, I spent 2 months living in the remote Chinese province of Ningxia.  One of the highlights of the trip was a visit to an old friend of my grandfather and a practitioner of traditional medicine (followed by an awesome lunch with “deer penis wine”).  He remarked that unlike western pharmacology, he didn’t know how each of the ingredients he prescribed broke down and functioned. He just knew that certain combinations worked.  His proof was in the people who got better.

In many ways, Public Health views having health insurance and going to the doctor in the same way.  We think insurance is good and people should have them.  Ditto primary care physicians.  We observe that people with them have better health outcomes than people who don’t.  But we’re not sure why.  Does insurance get you better doctors?  Is it the peace of mind?  The old pharmacist could compare the results of 2 equally sick people, one with herbal treatment and one without, to see whether his treatments work.  But Public Health can’t easily do that.  People with insurance are different from people without.  People without insurance tend to be younger, sicker, and have lower-income than people with insurance*.  So comparing the 2 groups is like comparing apples and oranges.  If only we could grab 2 similarly orange people without insurance and say, “you get insurance and you don’t,” and wait to see what happens.
If only.

The brilliant and articulate Dr. Kate Baicker from Harvard (who I’ve mentioned here) found a way.  She and her team seized upon a natural experiment from the state of Oregon.  In 2008, Oregon realized that it could afford to take on an extra 10,000 people in its Medicaid program (public health insurance for low-income people).  The need was much greater than 10,000.  So Oregon held a lottery. This way, the people who were randomly selected would be similarly orange to those who weren't.  Baicker et al tracked both groups over time and looked at their health, their use of health services, and how much they spent on healthcare—setting up a way to analyze the ‘effect’ of having Medicaid.  This is an important feat because the ACA is about to expand many Medicaid programs. It’d be good to know if these resources are being put to good use. 

So, how’d it go?  Oh look, we’ve run out of room again.  You’ll have to check back next week.  (If the suspense is really killing you, this has been all over the news: see here, here, and here).

*From the Kaiser Family Foundation: a wicked good resource on health policy basics.

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