O-Aren't-You-Glad Part 2: Even Gladder

(Previously: I visited a Chinese medicine lab and Oregon had Medicaid lottery...)

(Traveler Tip: Have One of These on Hand)

Wandering down the streets of Taipei one morning, Ashley, Baby Syd, and I popped into a random traditional medicine practice so Nurse Practitioner Ashley could check out what Chinese medicine was all about. In my travels, I'd observed that though Taiwanese people were friendly to begin with, having an adorable white baby on hand guaranteed premier service everywhere.  Except there.  The doctor seemed bored by our presence.  Given Ashley's father's collection of Australian aboriginal remedies for snake bites, we asked what he'd prescribe for snake bites.  It was then that his attitude turned from curmudgeon to contempt, as if we asked if his medicine was magic.  "If a snake bites you, go to a hospital.  Why would you ask for for traditional medicine then?" He replied (quite sensibly).  "You'd want to remove the venom.  Call 119 and go to a hospital for that."

Two weeks ago, I left you in suspense with the outcome of the Oregon Medicaid study.  Here goes: About two years after eligible adults were randomly chosen to enroll in Medicaid or not, the people with Medicaid coverage went to their doctors more (and in turn, had more tests done) than people without.  They also spent less money on healthcare and were less likely to be bankrupt by illness.  Medicaid bought peace of mind.  Enrollees reported higher quality of life and were less likely to have depression.  They were also more likely to take their diabetes medications.  Read here for one enrollee’s experience.  Those were the good bits. 

However, when it came to health outcomes, the Medicaid group wasn’t significantly different from those without.  What are we to make of this?  Is Medicaid any good?

One way to look at this is to say that people without insurance, like their Medicaid counterparts, know to go to the hospital for snake bites.  When it comes to the big illnesses, people find a way of getting medical care.  Doing so comes at a greater financial and emotional cost without Medicaid.  Another perspective is to question the effectiveness of our healthcare system, and the quality of doctors that Medicaid patients (and indeed, all patients) see.  The enrollees are going to the doctors but the doctors aren't delivering.   A third perspective is to say that maybe two years aren’t long enough to observe health differences, perhaps we’ll see an effect in a few more years.  I think all three are at work.

The Oregon study reiterates the importance of having health insurance.  Saving people from depression and bankruptcy are not small feats.  Yet it also remind us of the work cut out for Public Health.  It doesn't stop at policies that enable healthcare access.  Improving healthcare quality, and in turn the population's health, is much trickier.  Good thing I’ve chosen to explore it for my doctoral thesis.  

YoungerCare, RomneyCare, and ObamaCare

(Mark and Ash; Photo credit: Julie Aleman via Facebook)

Mark and Ash  are not the faces of the uninsured.  With degrees in engineering, business, public policy, nursing, and public health, they are the faces of the exhaustively educated and eminently employable.  Their story of scrambling for coverage then, reveals just how unaffordable healthcare is without insurance, and how close uninsurance can hit.

Shortly after their dual graduations from Harvard in 2010, the Youngers found themselves in a pickle.  Before they moved halfway across the world for Mark’s new job, they needed 6-months in California to tidy up affairs—mastering hot yoga (M); not-mastering embroidery (A); and most importantly, gestating (A).  Though they were young, healthy, and had a job in hand—3 markers of being low-risk insurers like in their beneficiaries— Ash’s pregnancy was considered a “pre-existing condition” and cause for denial even if she was previously insured.  They did not qualify for Medicaid.  And though ObamaCare promises an end to coverage denials like these, the clause does not kick in until 2014.

Public Health cares about insurance because it is a gateway to healthcare in the US.  It provides ease of mind, encourages healthy behavior, and mitigates the consequences of disease when they occur.  Insurance may not guarantee good care, but it is the first step toward care.  Given the high value of coverage, insurers are wary of people with pre-existing conditions because they’re so expensive: women who are preggers are almost guaranteed to have physician visits, tests, and a hospitalizations.  All those things cost money.  

(Offspring #1 and Offspring #2; Photo credit: Ashley Younger via Facebook)

 Lucky for Mark and Ash, though Californian insurers weren’t accommodating, Massachusetts guarantees coverage regardless of pre-existing conditions.  Massachusetts insurers could afford to do this because of the “individual mandate” put in place by RomneyCare ‘06.  By requiring everyone in the state to have insurance, the mandate widened the pool of people sharing risk, lowering the cost of covering expensive people.  ObamaCare works with a similar mechanism that is not yet in effect.  As for what RomneyCare ’12 will bring, Governor Romney has threatened to repeal all of ObamaCare.  He has also promised to cover those with pre-existing conditions provided that they have continuous coverage, but has provides few additional details on how his plan would cover such individuals (see this guide to pre-existing conditions for more info).

Mark and Ash never expected to be uninsured.  And thanks to RomneyCare ’06 (which was a model of ObamaCare), they didn’t have to be.  Rather than worry about how they’d pay for the birth of Offspring #2  (which came to over $30K for a “nothing fancy,” straightforward delivery), they could focus on other things, like how Duke + Harvard left them so poorly prepared for simple games like Boggle. 

Policy Implication:  The individual mandate is one solution to expanding coverage while avoiding adverse selection.