ObamaCare Done Right

Scandalous with Jennifer Hudson from Jennifer Hudson

The Affordable Care Act made funny, clear, and Olivia-Pope-y.  This is how you explain things.  

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.

ObamaCare at Year Three

With the exception of my uncle, who asks me about the health benefits of red wine (to get me to condone his drinking), people tend to only ask me one public health question: What do you think of ObamaCare? 

The Patient Protection Affordable Care Act (formerly known as PPACA, now known more commonly as the ACA, Health Care Reform, or ObamaCare) celebrates its 3rd birthday this week. As someone who majored in sociology at Bowdoin College, it’s been thrilling to have people take interest in what I study. I love talking about Health Care Reform.

(Pictured:  Found the knife and sticks in my room at my parents' house.  I think I wanted to whittle my own spear in middle school.)

I think of it like my little Swiss Army knife: a knife blade, a screwdriver, a nail file, a pair of scissors, a toothpick, and tweezer in one.  I’ve carried one around for years, though not the same one.   Most days, I forget that I have one— hence the many, many knives I’ve donated to the TSA.  And that time at nerd camp when I had to turn it in as "contraband."  But every once in awhile, when a package arrives or a Swedish bookshelf needs assembling, this little tool becomes very handy (see also MacGyver, Angus).  The ACA works the same way.  It doesn’t affect my life most days.  My relationships with my doctor and insurance company have not changed much in 3 years, nor the price I pay for these things.  But as I already know from the experience of my family and friends, it will be very handy when I need it.

If this analogy all sounds a lot like how we think of health insurance, it makes sense.  The main focus of the ACA was coverage expansion.  It was about allowing young adults to stay on their parents’ health insurance, about closing the ~$3000 coverage gap on medications for elderly people, helping people find and purchase insurance, and much more.  For more details, the Kaiser Family Foundation has the full deets on what’s in the ACA in both short and long form.

Though it can get you out of all sorts of jams, the Swiss Army knife is no panacea.  The little blade can cut through cardboard boxes, but it can’t chop down trees.  It’d be silly to expect it to.  Similarly, though the ACA has provisions that encourage efficiency, it won’t drastically reduce healthcare costs or trim our obesity rates.   And yes, there are bits that anger this group but pleases another, like the changes in how we pay some doctors, limits to how much insurance companies spend on non-medical expenses, and increase Medicare taxes for high-income earners.  Yet for the most part and for most people, the ACA hasn't and won’t affect your insurance status or fees.  It’ll just be there when you need help.  

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.