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.  

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.

Medicaid Done Right

This afternoon, I was running on the treadmill and listening to an old Planet Money podcast (yes, let the record show that I both exercised and learned economics via NPR today), and was startled to hear a familiar voice.  Even though "some of my best friends" are teachers, I still find it weird to spot my own outside of the classroom.  Yet there one was.  Professor Kate Baicker was on the radio (the cool kids do not have a nickname for her, because we were never actually cool enough to talk to her much) and explaining the effects of Medicaid in a simple, beautiful way that I admire.  It's exactly what I'm trying to do here.  But like DHem, she does it much more eloquently.  Check it out, if you haven't already.