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Obamacare, the Oregon Experiment, and Medicaid

Tomorrow, as mandated by the Patient Protection and the Affordable Care Act (PPACA, often called just the Affordable Care Act, or ACA, or “Obamacare”), the government-maintained health insurance exchanges will open for business (that is, assuming the likely government shutdown doesn’t stop them temporarily). We here at SBM have written about the ACA quite a few times, but I would like to write about it in perhaps an entirely different context than you’re used to now that the biggest change mandated by the law is here. Just to see the contrast, I’ll mention that Jann Bellamy has written about the ACA in the context of how provisions have been inserted by promoters of “complementary and alternative medicine” (CAM) could potentially provide an “in” for requiring reimbursement of CAM practitioners for their services by insurance plans sold through the exchanges or even how CAM practitioners might promote themselves as primary care providers (PCPs) under Obamacare, as did Matt Roman. I myself warned about legislative meddling that might permit funding of religion-based health care in the exchanges, and Kimball Atwood sounded early warnings about insertion of the provisions that Jann warned about. Instead, view this discussion as a follow-up to a post I did almost a year ago that used a statement by Mitt Romney during the height of the Presidential campaign as a jumping off point to look at the relationship between health insurance status and mortality. While we at SBM try to remain more or less apolitical, in some cases (licensing of naturopaths, for example) it is not possible to disentangle science from politics, and we have to dive in. Also, politics is the art of the possible; so, policy-wise, what is best as determined by science might well not be what is possible politically.

The reason I wanted to revisit this topic is because of a political battle that went on for quite some time over the last several months to expand Medicaid in Michigan according to the dictates of the ACA. The reason that this battle is occurring in many states is because when the Supreme Court ruled last year that the individual mandate requiring that citizens have health insurance was Constitutional, one provision that it ruled unconstitutional was the mandatory expansion of Medicaid in states participating in the Medicaid program to cover all people under 65 up to 133% of the federal poverty level. States thus had to decide whether or not they would accept the Medicaid expansion. In our state, Governor Rick Snyder supported the expansion. Even though he is Republican, he is also a businessman and realized that it was a good deal, with the federal government covering 100% of the cost for the first three years and then phase down to 90% of the cost in 2020. The bill to expand Medicaid managed to pass the House of Representatives, but then it stalled in the Senate. Unfortunately—and this is what got me involved—my state Senator Patrick Colbeck led the opposition to the Medicaid expansion in the Senate, much to my chagrin and disappointment. His argument, which is being repeated elsewhere in the blogosphere, is that Medicaid is worthless and doesn’t improve health outcomes. Instead, he endorsed an alternative that (or so he claimed) places Medicaid-eligible patients into in essence low cost, high deductible concierge practices, with health savings accounts. This was a plan promoted by practices like BlueSky Health. Ultimately Mr. Colbeck lost, and Medicaid was expanded in Michigan in a plan that was characterized by John Z. Ayanian in this week’s New England Journal of Medicine as “a pragmatic pathway to link Republican and Democratic priorities for health care.”

However, the whole kerfuffle got me to thinking. In my post a year ago, I basically asked what the evidence was that access to health insurance improves health outcomes, but I didn’t really stratify the question into kinds of health insurance. Rather, I just looked at being uninsured versus having health insurance. After my little Facebook encounter with one of my elected representatives, I wondered what, exactly, was the state of evidence. So I decided to do this post. In the U.S., currently we have in essence three kinds of health insurance, broadly speaking: private insurance, Medicare, and Medicaid. Medicare, for those of our readers from other countries, is a plan that covers the medical care of people 65 and over and those receiving Social Security disability benefits. It is funded through payroll taxes and directly paid for by the federal government. Medicaid, in contrast, is a plan designed for low income people who fall below certain income levels. Also in contrast, it is jointly funded by the states and the federal government with each participating state administering the plan and having wide leeway to decide eligibility requirements within the limits of federal regulations that determine the minimal standards necessary for states to receive matching funds. Indeed, the loss of this leeway to determine the income level at which a person is eligible for Medicaid is one of the reasons the provision for Medicaid expansion was part of the Supreme Court challenge to the ACA. These days, most Medicaid plans hire private health maintenance organizations (HMOs) to provide insurance. Finally, what needs to be understood is that, compared to private insurance, Medicare reimbursement rates tend to be lower and Medicaid reimbursement rates are lower still, which is part of the reason why a lot of doctors don’t accept Medicaid. Increases in reimbursement under the ACA might well help this situation.

Observational evidence

With that admittedly lengthy introduction behind us, let’s look at the science of the question of whether Medicaid is as useless as Mr. Colbeck and others claim that it is. It’s a huge set of studies, many conflicting and many also unable to control completely for confounders that interact with insurance status, such as socioeconomic status, risk factors like tobacco and alcohol abuse, and the like. Not surprisingly, unlike claims of Medicaid detractors, it’s complicated, and, like most complicated issues in medicine, there are studies that can be cherry picked by anyone to make whatever point he wants (which is exactly what my state Senator tended to do). A good place to start (for me, at least) is my original post from a year ago, because there was one study to which I alluded that showed differences in outcomes in cancer patients that correlate with their insurance status. Specifically, this is the University of Virginia study from 2010 which found that Medicaid and uninsured status were independently associated with increased risk-adjusted mortality. I mentioned that, but didn’t dwell on it, because the question I was examining was not Medicaid versus private insurance but rather having health insurance versus no health insurance. In this study, however, the authors noted the multifactorial causes of poorer outcomes in Medicaid patients. There are other studies that find similar outcome disparities. For instance, using the National Inpatient Sample (NIS) database, which is a stratified random sample of all hospital discharges in the United States maintained by the Agency for Healthcare Research and Quality as part of the Healthcare Cost and Utilization Project, a 2003 study from the University of Michigan found that for abdominal aortic aneurysms (AAA) uninsured and Medicaid status were associated with higher mortality and rupture rates:

Operative mortality rates after elective AAA repair were greater (P =.04) for patients with no insurance (2.6%) or Medicaid (2.7%), compared with patients with private insurance (1.2%). Similarly, operative mortality rates for AAA repair after rupture were greater (P =.001) in patients without insurance (45.3%) or Medicaid (31.3%), compared with patients with private insurance (26.2%).

Of course, in this study, Medicaid patients did better than the uninsured for some outcomes. For instance, if you look at the adjusted odds ratio for AAA rupture, Medicaid status had no effect, with an odds ratio of 0.84 (0.55-1.3, p=0.41), while no insurance produced an odds ratio of 2.3 (1.5-3.5, p=0.001). From the point of view of this study, it is better to have Medicaid than to be uninsured but not as good as having private insurance. This is not entirely surprising because of the low reimbursement rates of Medicaid, which limit the choices of physicians and institutions for Medicaid patients and make it prohibitive for many private primary care doctors to care for Medicaid patients. Similar results were found in a 2011 study of cardiac valve replacement from the University of Virginia, which showed the best outcomes in terms of mortality and in-hospital complications in patients with private insurance, followed by Medicare patients, Medicaid patients, and the uninsured, who had the worst outcomes of all. They also reported that Medicaid patients accrued the longest hospital stays and highest costs. Consistent with this, a 2013 study from the University of Virginia of pediatric surgery patients undergoing mostly urgent surgery for appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung’s disease showed that uninsured patients were at increased risk for mortality, while Medicaid patients were at increased risk of morbidity.

Of course, the question really boils down to whether it is equivalent to be uninsured versus having Medicaid, which some studies seem to indicate, or not. Again, this is a very complicated question, because studies looking at specific outcomes can be confounded by uninsured patients getting Medicaid. For instance, uninsured patients who are diagnosed with cancer in our state frequently qualify immediately for Medicaid and are no longer uninsured. This leads to a rather frustrating situation for some of my patients who are uninsured and suspected of having cancer but can’t afford the biopsy necessary to prove it and make them eligible for Medicaid. We have other resources, including limited state funds and charitable funds administered through our cancer center that can pay for such biopsies, but it’s very frustrating to cancer doctors that such resources are even necessary given how great the need is.

All of this leads to a potential explanation, and quite a reasonable explanation at that, as to why Medicaid patients do more poorly than patients with private insurance in some studies (the ones touted by Mr. Colbeck as indicating that Medicaid is worthless and doesn’t improve health outcomes), and that’s the delay in treatment. This was alluded to as a possible cause in the AAA study from 2003, but it’s suggested more explicitly as a cause in a 2012 study from the Brigham and Women’s Hospital examining outcomes after surgery for spinal metastases. This study found higher mortality rates for the uninsured and Medicaid patients, as well as higher complication rates. However, these were crude estimates. When the investigators adjusted for acuity of presentation, there was no significant differences in the risk of death or complications between privately insured patients and Medicaid patients or the uninsured, leading the authors to conclude that, “This nationwide study suggests that disparities based on insurance status for patients undergoing surgery for spinal metastases may be attributable to a higher acuity of presentation.” A recent systematic review of outcomes in lung cancer patient mortality came to similar conclusions:

The mechanisms underlying care disparities for patients without insurance and for those who receive Medicaid are unclear but probably multifactorial (6, 41). There are likely patient-related factors, such as individual differences in health behaviors such as smoking, income, education, and comorbidities. Others may stem from a differential ability to interact with the healthcare system, differences in the care provided by institutions that serve Medicaid and uninsured patients, and less access to better-quality care. Our review indicates that some of these latter mechanisms may be important based on studies that show differential rates of receiving guideline-concordant care (31, 32), receiving care at a university cancer center (29), receipt of surgery or radiation therapy (20), and receipt of care at high-volume centers (27, 28). Although uninsured patients and those with Medicaid may be more likely to be treated at certain centers, no studies directly adjusted for center-level effects, so we cannot determine their role on the assessed outcomes (42).

Taken together, from my perspective, the evidence is consistent with a conclusion that having Medicaid results in better health outcomes than not having Medicaid but that those outcomes are not as good as those associated with having private insurance (although one study did find a paradoxical result). Most likely this is due to a combination of socioeconomic status and lack of primary care resources, all leading to their presenting at a later stage in their disease, as these studies, which are just a more recent sampling of existing studies, clearly indicate. For some conditions, Medicaid patients do as poorly as the uninsured, and those are the studies cited by legislators like Mr. Colbeck to argue against Medicaid expansion. Sometimes they are intermediate in their outcomes, not as good as patients with private insurance but not as bad as the uninsured. These tend to be the studies ignored by legislators like Mr. Colbeck and the pundits that he cites. However you analyze the evidence, however, it is clear that Medicaid patients do have worse outcomes, sometimes a lot worse, than patients with private insurance, and that the cause is almost certainly multifactorial in such a way that simply getting access to bare-bones health insurance like Medicaid can’t remedy. Many of these studies have unmeasured confounders that result in worse outcomes in Medicaid patients. As Frakt et al have argued, selection bias in these studies explains a lot of the results:

It’s far more likely that such results are driven by selection bias. Medicaid enrollees (including dual-eligible recipients of both Medicaid and Medicare) tend to be sicker than uninsured patients and to have lower socioeconomic status, poorer nutrition, and fewer community and family resources. Medical and social service providers may also help the sickest or neediest patients to enroll in Medicaid — a more direct cause of selection bias. Few of these potential confounders can be completely addressed using commonly available clinical or population data.

Health economists use an alternative approach in analyzing Medicaid’s outcomes that seeks to eliminate selection bias related to unobservable factors affecting enrollment and health outcomes. By exploiting the variation in Medicaid eligibility rules or other program characteristics influencing states’ enrollment rates, scholars have consistently found that Medicaid coverage leads to health improvements.4,5 The assumption behind these “instrumental variables” approaches is that Medicaid enrollment depends on state-level eligibility rules but patients’ health status does not.

Personally, I suspect that there is a lot of selection bias in these studies. Young healthy adults without insurance who are eligible might not enroll in Medicaid because they don’t think they need it and also tend not to need the procedures examined in the studies I discussed. In contrast, if you’re sick and eligible for Medicaid, you’ll be more likely to enroll because you need the treatment. Also, as I’ve pointed out before, in studies of cancer, there is a lot of crossover between the uninsured and Medicaid recipients, because in some states like mine a cancer diagnosis makes an adult who might not have been eligible for Medicaid (remember, some states restrict Medicaid eligibility using more than just income) will suddenly become eligible. I’ve lost count of the number of patients I’ve taken care of for whom this was true. The same thing happens in emergency rooms all over the place, where hospitals, confronted with an uninsured patient, help him apply for Medicaid during the course of an acute illness.

Would expanding Medicaid result in better health outcomes?

Of course, the name of this blog is Science-Based Medicine, and the question that results from the confusing and conflicting mass of studies sampled above is whether expanding Medicaid would result in better health outcomes for the people who receive the expanded coverage. This is a much more difficult question to answer, but there have been studies designed to address it. The two most prominent are frequent “targets” of discussion. The previous studies that I’ve cited are all retrospective studies, with all the attendant shortcomings of retrospective studies, and none of them address this question. They simply found correlations, and some of them tried to explain these correlations.

One study that is often touted as strong evidence that expanding Medicaid eligibility will likely result in better health outcomes was a study published in the NEJM a year ago. What the investigators did was to identify states that had expanded Medicaid to cover childless adults (in many states childless adults have not been eligible for Medicaid coverage) between 2000 and 2005 to allow comparisons for a five year period before the expansion and after the expansion:

Three states met our criteria: Arizona, which expanded eligibility to childless adults with incomes below 100% of the federal poverty level in November 2001 and to parents with incomes up to 200% of the federal poverty level in October 2002; Maine, which expanded eligibility to childless adults with incomes up to 100% of the federal poverty level in October 2002; and New York, which expanded eligibility to childless adults with incomes up to 100% of the federal poverty level and parents with incomes up to 150% of the federal poverty level in September 2001.

The controls selected were neighboring states without Medicaid expansions that were closest in population and demographic characteristics to the three states with Medicaid expansions. The primary outcome examined was annual county-level all-cause mortality per 100,000 adults between the ages of 20 and 64 years (stratified according to age, race, and sex), obtained from the Compressed Mortality File of the Centers for Disease Control and Prevention (CDC) from 1997 through 2007, totaling 68,012 observations specific to an age group, race, sex, year, and county. Secondary outcomes included percentages of persons with Medicaid, without any health insurance, and in “excellent” or “very good” health (from the Current Population Survey, a total of 169,124 persons) and the percentage unable to obtain needed care in the past year because of cost (from the Behavioral Risk Factor Surveillance System, a total of 192,148 persons). Multivariate analyses were carried out, and prespecified subgroup analyses, and as an additional test the same analyses were carried out for people over 65, who were eligible for Medicare and whose Medicaid eligibility was therefore not affected by the Medicaid expansion. Overall, the investigators found a 6.1% relative reduction in the risk of death among adults between the ages of 20 and 65, leading them to estimate this:

A relative reduction of 6% in population mortality would be achieved if insurance reduced the individual risk of death by 30% and if the 1-year risk of death for new Medicaid enrollees was 1.9% (Table S4 in the Supplementary Appendix). This degree of risk reduction is consistent with the Institute of Medicine’s estimate that health insurance may reduce adult mortality by 25%, though other researchers have estimated greater35 or much smaller36 effects of coverage. A baseline risk of death of 1.9% approximates the risk for a 50-year-old black man with diabetes or for all men between the ages of 35 and 49 years who are in self-reported poor health. The lower end of our confidence interval implies a relative reduction in the individual risk of death of 18%.

This study did, of course, have a fair number of confounders and shortcomings. For one thing, it was not a randomized design, and it was an ecological study, which tends to overestimate effects. Also, as the authors point out, states tend to decide to expand Medicaid when the economy is doing well and they can afford to do it. Also, there is a correlation between states willing to expand Medicaid and investment in other measures designed to improve public health. On the other hand, the authors reported found that new Medicaid enrollees tended to be older, disproportionately minorities, and twice as likely to be in fair or poor health as the general population, all of which to them suggested a higher risk of mortality. In other words, this study was promising, but by no means slam-dunk evidence that Medicaid expansion will result in better health outcomes.

The Oregon study

No discussion of this issue is complete without a consideration of a study in Oregon designed to look at the effect of Medicaid expansion. Its most recent results were reported in the NEJM five months ago and were seized upon by advocates on all sides, but in particular the “Medicaid expansion doesn’t work” and “Medicaid is harmful” side. It’s a curious study in that, had it been proposed to me before I already knew that it had been begun, I would have seriously questioned whether the study was ethical and would pass an institutional review board. Obviously it did, and the reason is that it wasn’t the investigators who did the randomization. Rather, Katherine Baicker and her colleagues took advantage of an existing randomization. What happened is this. In 2008, because its legislature found the money to fund additional Medicaid coverage, Oregon used a lottery system to determine who of a waiting list of 90,000 would have a chance at getting Medicaid. Selected adults won the right to apply for Medicaid and got it if they met the eligibility requirements. A sample of adults who won the Medicaid lottery were compared to adults who participated in the lottery but didn’t win. Outcome measures examined included blood-pressure, cholesterol, and glycated hemoglobin levels; screening for depression; medication inventories; and self-reported diagnoses, health status, health care utilization, and out-of-pocket spending for such services. This sample was limited to the Portland metropolitan area because of logistical constraints and consisted of 20,745 people: 10,405 selected in the lottery (the lottery winners) and 10,340 not selected (the control group), of which a total of 12,229 persons in the study sample responded to the survey. Interviews were conducted between September 2009 and December 2010 and took place an average of 25 months after the lottery began.

This was a rare opportunity to take advantage of an existing natural experiment in whether providing Medicaid coverage to the uninsured actually does what it is intended to do. Unfortunately, given its timing, the results of the study have become a political punching bag with the Oregon study in essence being used as a weapon against the whole of Obamacare and misrepresented as being slam dunk evidence that Medicare is at least useless. In essence, as Ashish Jha put it, the Oregon Study became a Rorschach test of sorts, confirming people’s biases about whether Medicaid is “good” or “bad.”

So what did it show?

The results were mixed and rather disappointing in some respects but not entirely unexpected given the short follow-up time of only two years:

We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (−9.15 percentage points; 95% confidence interval, −16.70 to −1.60; P = 0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.

As has been pointed out at The Incidental Economist, this led those opposing Obamacare to declare the experiment a failure. Some go so far as to declare that the ACA has completely failed, that Medicaid is a horrible thing, and that anyone who tries to argue against this is a “Medicaid denier.” (I kid you not; unfortunately, Avik Roy, a “health policy columnist” for Forbe.com, used this very term. One notes that Mr. Roy is a person known for making seriously bad arguments.) Unfortunately, my state Senator buys into these arguments. I also agree with Jha when he challenges physicians to go through all 62 pages of the supplementary appendix describing the methodology in detail because this study is as good as any study on the matter likely to be done in a generation.

So is it really as bad as that? Of course not. The study is, as are most studies of this type, messy and early results are disappointing, but by no means is it time to declare failure yet. For one thing, improved mental health outcomes are improved outcomes. The way critics of Medicaid ignore this result or pooh-pooh it to me is consistent with how we give short shrift to mental health in this country, viewing mental illness as somehow not being “real” illness. Also, the marked decrease in financial distress reported in this study is no small thing. For another thing, lack of statistical significance doesn’t necessarily mean that there is no treatment effect. It can mean that, but it can also mean that the numbers are too small and the study is underpowered, which it could well be. Indeed, the authors themselves concede as much:

Hypertension, high cholesterol levels, diabetes, and depression are only a subgroup of the set of health outcomes potentially affected by Medicaid coverage. We chose these conditions because they are important contributors to morbidity and mortality, feasible to measure, prevalent in the low-income population in our study, and plausibly modifiable by effective treatment within a 2-year time frame. Nonetheless, our power to detect changes in health was limited by the relatively small numbers of patients with these conditions; indeed, the only condition in which we detected improvements was depression, which was by far the most prevalent of the four conditions examined. The 95% confidence intervals for many of the estimates of effects on individual physical health measures were wide enough to include changes that would be considered clinically significant — such as a 7.16-percentage-point reduction in the prevalence of hypertension. Moreover, although we did not find a significant change in glycated hemoglobin levels, the point estimate of the decrease we observed is consistent with that which would be expected on the basis of our estimated increase in the use of medication for diabetes. The clinical-trial literature indicates that the use of oral medication for diabetes reduces the glycated hemoglobin level by an average of 1 percentage point within as short a time as 6 months.15 This estimate from the clinical literature suggests that the 5.4-percentage-point increase in the use of medication for diabetes in our cohort would decrease the average glycated hemoglobin level in the study population by 0.05 percentage points, which is well within our 95% confidence interval. Beyond issues of power, the effects of Medicaid coverage may be limited by the multiple sources of slippage in the connection between insurance coverage and observable improvements in our health metrics; these potential sources of slippage include access to care, diagnosis of underlying conditions, prescription of appropriate medications, compliance with recommendations, and effectiveness of treatment in improving health.

The Incidental Economist thinks that most likely the reason that the results, although trending in the right direction, didn’t achieve statistical significance was because the study was underpowered. Jha thinks it’s because Medicaid only addresses access to care and not quality of care. Both are likely contributors, but I tend to think that The Incidental Economist is likely to be closer to being correct. Contrary to analyses claiming that this study was not underpowered, for a controlled study of this type, the fraction of subjects with each condition very much matters. If only 5% of the population have a condition, that’s only around 300 subjects in each group. When looking at all these subgroups, absent dramatic improvements in certain parameters or high prevalence of the conditions being examined, it is hard to detect statistically significant differences, particularly in a short time frame. Finally, these measures are all surrogate measures. What will really be interesting to determine will take considerably more time than two years to determine, namely whether Medicaid coverage decreases morbidity and overall mortality. Indeed, The Incidental Economist asks a very pertinent question: “What is reasonable to expect? How much does private insurance affect these values? Do we know? No. There is no RCT of private insurance vs. no insurance. No one claims we have to have one. We just “know” private insurance works.”

The bottom line

As I stated earlier, as much as we would like political policy to be science-based, particularly in health care, it can’t be said enough that politics is the art of the possible, and the ACA is what was possible at the time it was being negotiated. As a product of a messy political process, it is far from perfect. The question is whether the claims made for the ACA and its provisions are supported by evidence. Because a large part of mechanism by which the ACA will decrease the number of uninsured is through the Medicaid expansion, studies like the Oregon study are very important for determining whether it has a reasonable chance of succeeding in improving the health outcomes of these people. As is all too frequently the case, the error bars are large surrounding the data relating Medicaid and health outcomes, and unfortunately the most recently reported results of the Oregon study come after too brief a time to make any definitive pronouncements, attacks on it by anti-Obamacare pundits notwithstanding. Moreover, when it comes to public policy, science is certainly a major consideration, but so are economics and justice. Reasonable people might disagree on where the balance should be struck, but nothing is served by distorting the science for political ends. Unfortunately, there is a lot of that going on right now and, I suspect, it will only get worse before it gets better.

Posted in: Clinical Trials, Epidemiology, Politics and Regulation, Science and the Media

Leave a Comment (74) ↓

74 thoughts on “Obamacare, the Oregon Experiment, and Medicaid

  1. DugganSC says:

    I’m about halfway through the article, but I was reading the bit about how results may be worse because sick people are often the ones signing up for Medicaid. I wonder whether the results for private insurance are similarly inflated in the other direction because insurance companies could legally exclude people with pre-existing conditions, meaning that the person above the poverty line who finds out he has cancer has difficulty getting insurance while the one below can.

    I don’t think it’s likely to be large confounder, but it is something to consider.

    1. Carl says:

      Normal insurance would be biased in the opposite direction in the case of an insured person being dropped after they get sick. Denying “pre-existing conditions” keeps everyone in the same category as they were when they got sick. This is normally what you would want to have accurate statistics.

      1. DugganSC says:

        {nods} I’m arguing that the current system has a further bias involved in it in that you can only be seriously ill with these conditions in the “private insurance” sector if you developed your condition afterwards. And yes, exempting pre-existing conditions works with the caveat that, in my opinion, it only works with the insurance mandate to avoid the “I’ll get insurance when I’m sick” gambit.

        1. Carl says:

          Right, but the tendency for young people to not get insurance until they are old and about to get sick (even before anything actually happens) would tilt the “insured” category towards looking bad.

          1. windriven says:

            @Carl

            ” [T]he tendency for young people to not get insurance until they are old and about to get sick…”

            And this is a perfectly rational behavior for a healthy young person given the current system. They have a low probability of developing a serious illness and common injuries (i.e. traffic accidents) can be covered, at least in part, by other insurance. Further, they generally have few assets so bankruptcy is not a particular fear.

            We all consume health care to one degree or another. It is reasonable to expect everyone to contribute to the health care system.

          2. WilliamLawrenceUtridge says:

            Keeps costs down on a per-insured basis, then entire basis of the system is distributing the costs of those who are ill among the entire population, most of whom are not.

    2. Rick says:

      If you have pre-existing conditions you can be only excluded (at least in Michigan) if you are trying to buy an individual policy. The majority of people still get insurance through their employer so this isn’t a problem for them; however, they would me more likely to get early diagnosed and have better choices of treatment.

      1. windriven says:

        Indeed, 68% of the employed population is ensured through their employer.

    3. brian says:

      I think we need this like a century ago . before my daughter got tuberculosis at public school more people get treatment Les people are sick and a stronger work force. but I take my animals to vet, so why should i think that a human deserve any less. unless only your a some cracker who thinks only the privileged deserve medical . TO that i say fool get over it we pay taxes as a people and all deserve human kindness

  2. I only have 1 thought about Obamacare:

    1. The sooner it’s repealed the better

    1. windriven says:

      “I only have 1 thought about Obamacare:”

      FBA, it is arguable whether you are capable of meaningful thought at all. It is no surprise that your braying joins the cacophony of dolts and dweebs who find comfort – and in some cases exceptional profits – in the return to a system that denies quality health care to many while consuming twice the fraction of GDP than most competitive systems.

    2. WilliamLawrenceUtridge says:

      I only have 1 thought about Obamacare:

      1. The sooner it’s repealed the better

      Of course you do. The more people have access to real medicine, the less they will take advantage of your services as a cheaper option to real medicine. The fact that they will be healthier is of absolutely no concern to you.

      1. Carl says:

        …unless of course these clever quacks figure out how to work the new “discrimination” clause and force insurers to pay for nonsense.

    3. goodnightirene says:

      Well, think again–oops! You only have “one thought”. Too bad.

      As a quack, I would think you’d be delighted by the insertions of the bits that want to pay such as you and even call them “primary providers”.

      1. The modest benefits to me personally dont even begin to compensate for grievous harm Obamacare will inflict on the country. I hope the current government shutdown will result in the complete defunding of this monstrosity, but I am not optimistic.

        1. Chris says:

          Please provide details, with verifiable documentation, of the “grievous harm” harm that will happen do to the Affordable Care Act. I dislike generalities, and the legislation is very complex. So please explain.

        2. WilliamLawrenceUtridge says:

          Watch the news, the current shutdown is not interfering with the implementation of Obamacare.

          Heh, a naturopath and a Republican. Unsurprising since both come front-loaded with deliberate scientific illiteracy.

  3. windriven says:

    “[T]he evidence is consistent with a conclusion that having Medicaid results in better health outcomes than not having Medicaid but that those outcomes are not as good as those associated having private insurance.”

    “For some conditions, Medicaid patients do as poorly as the uninsured, and those are the studies cited by legislators like Mr. Colbeck to argue against Medicaid expansion.”

    And in this argument Mr. Colbeck marks himself both fool and asshole. If we accept the argument that Medicaid patients do as poorly as the uninsured then the action demanded is to improve Medicaid not to throttle it. The United States is still by any measure among the wealthiest nations on earth*. By what argument does the world’s largest economy deny basic health care services to any of its citizens? Other vibrant industrial economies remain competitive while delivering extremely high levels of health care and other social services to their citizenry. I offer Sweden, Denmark, Germany and Norway as examples.

    What then is the political or economic argument of Mr. Colbeck and his allies? Where is Mr. Colbeck’s superior alternative to ACA? The nation is listening and the silence is deafening.

    ACA suffers from many deficiencies. It is not in any sense health care reform, it is quite modest health insurance reform. Despite the many promises that ACA will reduce costs it will almost certainly cause costs to rise**. The American people are, by most surveys, deeply skeptical about ACA and the benefits it promises to bestow. In fact its only advantage is that it is a little better than what we have now!

    Any ACA opponent with a broad and coherent rival plan to provide coverage for all Americans while reducing cost as a percentage of GDP could probably get him or herself elected god. Yet those on the spastic right offer exactly nothing except a return to the status quo. For this reason alone they will lose their bid to defund ACA and they will suffer the political consequences of any temporary government shutdown.

    *World Bank ranks US 7th in per capita GDP, IMF ranks US 6th, CIA ranks US 8th

    **The savings promised by ACA come mostly from reductions in provider payments. These, as anyone who has been paying attention, reimbursement cuts are politically impossible. Physicians and hospitals won’t work for free and can’t work at a loss. Nonetheless, CBO is required by law to ‘score’ budget savings by the law as written regardless of the history of similar measures. Finally, while ACA will increase the demand for physician services it makes no effort to fund additional residencies. Whether Keynesian or Austrian it is universally agreed that when growing demand meets inelastic supply, cost rises.

    1. Carl says:

      windriven says:
      “If we accept the argument that Medicaid patients do as poorly
      as the uninsured then the action demanded is to improve
      Medicaid not to throttle it. ”

      Or just trash the whole thing and have the government start an actual real insurance service tasked with providing real full service, not this bullshit patchwork where you pay taxes for it, but only get benefits if you are a specific category of person or if you prove that you are sick on your own dime.

      This was the first idea trashed during the debate, and instead we have a bunch of demands from the government that someone else give insurance away for free and laws requiring that those greedy insurance companies pay up, even though the government’s official policy is to always pay less than real insurance.

      1. windriven says:

        I have long thought that the US should expand the VA system and start folding Medicaid and Medicare recipients – on a voluntary basis – into a pure single payer system. This would test the government’s ability to deliver quality services at an affordable cost while avoiding the argument of socialist care. Hey, its just one more choice.

        Of course the insurance and hospital industries would shriek but who gives a crap? Oh … the elected officials tasked with serving our interests who instead serve themselves at the insurance and hospital PAC troughs.

        As an aside, the US spends roughly 17.6% of GDP on health care while Sweden spends 9.6%. Imagine the impact on health care for everyone if we knocked our expenditures down to Sweden’s level and then invested the saved 8% of GDP in medical research.

        1. David Gorski says:

          Indeed. And by most metrics the health care Swedes receive is as good or better than what Americans receive. Ditto most other developed countries, which spend one-half to two-thirds what the U.S spends and manage to cover nearly all their citizens. The current system in the U.S. is simply a very bad deal. It’s the worst of the free market and government systems.

          1. windriven says:

            I served on the board of directors of a Swedish company for a number of years and have some familiarity with their system. Quality of care is quite good. WHO ranks Sweden 23rd in quality versus 38th for the US. But the Swedes spend U$D 3758 per capita versus $8233 in the US (46%).

          2. windriven says:

            There have been arguments that WHO understates the quality of US care.* But I say to these critics: we spend more than twice per capita what the Swedes spend. Can you seriously believe that our care is twice as good?

            *And this is probably true for the wealthiest and best insured among us. But the last time I checked a single mother of three in Gadsden, AL is as much an American as Lloyd Blankfein. The Swedes treat largely with a blind eye to the stratifications that mark US healthcare.

    2. DugganSC says:

      My qualm with the ACA is namely what you state, that it’s going to drive costs up. The figures I’ve seen seem to indicate that the very poor will get affordable health care. The very rich will see a small increase in expenditures. The middle class is going to see rates go up, possibly beyond their means to cover. And the insurance companies and hospitals will, in the end, keep raking in the dough. I appreciate the intent behind the legislation, but in a country where healthcare is more expensive than any other first-world country, raising the expense is not going to make it better.

      That said, I’m hoping that when reality sets in, this will cause people to start looking for real solutions. As I said to a fellow I was talking at in the auto shop, I recognize that there are no perfect solutions, but we need something better.

  4. windriven says:

    I imagine that we will eventually end up with a single payer system. But instead of doing it intelligently and carefully and efficiently I expect we’ll careen from crisis to crisis while insurance companies and hospital chains rake in mind-boggling revenues and buy the votes of senators and representatives to keep the cream a-flowin’.

    It all gives free market capitalism a bad name. But of course there is nothing free about the US health care marketplace and almost nothing capitalist about it.

  5. windriven says:

    “[I]t can’t be said enough that politics is the art of the possible, and the ACA is what was possible at the time it was being negotiated.”

    That is probably true as the Republicans have not historically showed much interest in changing health care. But it is also true that the Democrats cut the Republicans out of any real dialogue or input into the act. The Republicans have no vested interest in ACA so they are able to pot-shot it at will.

    I am not suggesting that any meaningful segment of Republicans would have contributed positively had they had the chance. I guess we’ll never know. But the Sam Rayburns and Tip O’Neills left lasting legacies by skillful political maneuvering, an art sorely lacking in the leadership of either party these days.

    1. DugganSC says:

      *wry grin* Well, as repeatedly pointed out to skewer various Republican pundits, much of the ACA has been replicated in bills advanced by prominent Republicans, so I’d argue that yes, there probably would have been Republicans involved in the debate. How useful it would be, since said skewering is over said Republicans now being the staunchest opponents, is a matter of debate.

    2. Stella B says:

      To my eye the Ds just about bent over backwards trying to get at least a few Rs to participate in the debate, but the Rs just flat refused. That was then, though, and now the ACA is the law and deliberately damaging it while misrepresenting it as “socialism” seems to be the R strategy.

      Believe it or not, about 1/3 of the uninsured are unable to get insurance due to pre-existing conditions and many of them are neither poor nor unhealthy. I have a brother-in-law who is physically fit, runs a thriving small business and is uninsurable due to a bicuspid aortic valve which is a relatively common congenital condition. Since I’m a physician, I can reel off story after story of people who can not get insurance despite being relatively healthy and decidedly middle-class, 70 year olds forced to work for no reason other than to insure a younger spouse and 60-64 year olds who can no longe work due to DJD, but who can not afford knee or hip replacement until Medicare age. I have mild asthma (no tobacco ever) and advanced DJD for my age due to a mild congenital deformity (not my choice of lifestyle!). I’m not sure that I could be insured on the private market.

      The former CEO of United Healthcare, Bill McGuire, made between $1.6 and 1.8B as compensation in his final year in 2006. I’m really not concerned that Congress has decided to enforce some modest control on the insurers medical loss ratios. Clearly the “free-market” is not working in health care. The Rs controlled the Congress and the White House for six years and their only contribution to health care was a huge, unfunded addition to Medicare and a little messing around in one family’s private business. That they did not want to participate in the ACA debate reflects badly on them and not on the current president.

      1. windriven says:

        @Stella B

        “To my eye the Ds just about bent over backwards trying to get at least a few Rs to participate in the debate, but the Rs just flat refused.”

        Right you are, Stella. I had a total brain dump on this and remembered it as then-Majority Leader Pelosi locking the Rs out of the write-up process. But while she certainly engaged in some eye-gouging the Rs were equally combative from the start. Senator Reid was more proactive in trying to recruit Rs if only to create a fillibuster-proof majority. Ultimately not a single Republican senator voted for the bill. Shameful.

      2. Windriven says:

        @StellaB

        “The former CEO of United Healthcare, Bill McGuire, made between $1.6 and 1.8B as compensation in his final year in 2006. ”

        I wonder if you can give us a citation for this. I have no doubt that McGuire was wildly compensated. but $1.6 billion stretches credulity.

        1. cloudskimmer says:

          United Health Group
          It looks like $1.1 billion was a severance package, and later there were fines associated with backdating of stock options. It is hard to understand how anyone could be worth this much money, or how this happens in a country where health care is responsible for most bankruptcies, and most of these are among the insured. (See http://judiciary.house.gov/hearings/July2007/Himmelstein070717.pdf)

          I hope this works. It’s my first try using HTML tags. If not, the first reference was United Health Group on Wikipedia. There were many references to this story from 2006.

          1. windriven says:

            The backdating of stock options to inflate his compensation is indefensible – and apparently not particularly unusual. McGuire ultimately had to repay $475 million of his $1.6 billion – not much of a slap on the wrist. Had he, the CFO and members of the board all drawn significant prison terms, diddling with the books of publicly traded companies would begin to ebb.

      3. Denise B says:

        I was turned down for health insurance a few years ago and the reason I was given was that I use cortisone nasal spray for my allergies.

    3. David Gorski says:

      But it is also true that the Democrats cut the Republicans out of any real dialogue or input into the act.

      Except that it isn’t.

      http://www.businessweek.com/articles/2013-09-30/the-government-shutdown-is-john-boehners-fault

      1. Windriven says:

        Yup. I was wrong. I researched after StellaB’s comment and responded there.

      2. FastBuckArtist says:

        The govt needs to borrow 3 billion dollars every day just to keep the lights on, is that all Boehners fault too??

        Obamacare may actually have a few valid innovations in it, and IF it was financed out of tax revenues some discussion can be had on the healthcare merits of it, but it is entirely on the national credit card, so there is nothing to talk about, it has to be defunded immediately.

        1. WilliamLawrenceUtridge says:

          Not if it’s paid for out of borrowed overseas capital, that shifts the national debt towards the dollar devaluing, which improves exports to domestic and foreign markets.

          Not that I’d trust your ability to reason in political spheres, since you don’t seem to grasp something as basic as the why homeopathy can’t work, or why vitamin supplements are a waste of money for most people.

        2. WilliamLawrenceUtridge says:

          Also, I’ll take the time to point out that nearly every other country on the planet, certainly every first-world country on the planet, manages to have a health care system that delivers services to all of its citizens. Perhaps not optimal care that guarantees a cure, but even Steve Jobs, with a personal wealth of how many millions, couldn’t pay for that. And certainly his carrot juice and detoxing didn’t help.

          So perhaps Obamacare will be a time of national soul-searching, and reprioritizing, to allow the United States to join the other nations of the world in ensuring people don’t have to wait for a tumor to ulcerate through the skin before they get treatment.

        3. mousethatroared says:

          “Obamacare may actually have a few valid innovations in it, and IF it was financed out of tax revenues some discussion can be had on the healthcare merits of it, but it is entirely on the national credit card, so there is nothing to talk about, it has to be defunded immediately.”

          FBA is not just a Republican, he appears to be a tea partier, which requires an especially high reliance on delusional thinking.

          Surprised?

          FBA – It’s called the democratic process. Congress passed the ACA, it was signed by the president. The Supreme Court approved it. It has withstood forty attempts by the GOP to appeal it. The Presidential candidate who made it clear he would repeal the ACA, lost. Not only was the ACA passed, but it was passed and upheld with mandatory funding.

          You all had your chance to convince the people that it was too expensive, but failed. Because most of us consider it an investment that will pay off. Now a small faction of republicans who’s seats are virtually insured by gerrymandering, is holding the rest of the budget and the national economy hostage, in an effort to defeat The ACA, not through reason or negotiation, but fiscal threats.

          If the tea party and the republicans who are supporting the tea party believe in democracy, why won’t the let the house vote on a clean funding bill?

          1. WilliamLawrenceUtridge says:

            You all had your chance to convince the people that it was too expensive, but failed. Because most of us consider it an investment that will pay off. Now a small faction of republicans who’s seats are virtually insured by gerrymandering, is holding the rest of the budget and the national economy hostage, in an effort to defeat The ACA, not through reason or negotiation, but fiscal threats.

            As a foreign watcher of your extraordinarily interesting political process, I kinda hope this is the impetus that breaks the back of the current Republican party, forcing some sort of new set of options to rise out of the ashes. It’s happened before I believe (keeping in mind that I’m basing my knowledge on Dot Com from 30 Rock), and a renewal of that particular stream of political thought would be valuable, hopefully innovative. Perhaps it would even split into a more refined set of groups, libertarians (low social and fiscal control) and conservatives (high social control, low fiscal control). Separate the Tea Partiers from the Christian Right.

  6. Jane G says:

    It might not be exactly accurate to say we don’t have a health insurance RCT. We have the RAND study. That study was HUGE and randomized all income levels to great coverage, medium coverage, and essentially no coverage. http://www.rand.org/health/projects/hie.html

    1. David Gorski says:

      The RAND study didn’t study people without health insurance or, as I recall, people on Medicaid; so it’s not really as pertinent to the current discussion regarding Medicaid. It’s also not a randomized study that could ever answer what the effect of no insurance versus insurance is.

  7. Nova Squadron says:

    Is there a reason that your analysis appears limited to articles from medical journals? It is a thoughtful analysis I am just wondering because there are so many journals specifically devoted to healthcare economics that might offer a lot of insight.

    1. David Gorski says:

      For purposes of this analysis, I don’t care that much about the economics of the ACA. The purpose of this post was to determine whether or not there was any basis to attacks on the Medicaid expansion based strictly on the science. The articles I did come across in healthcare economics journal didn’t focus on this question enough and generally focused on, not surprisingly, cost and efficiency.

      1. Nova Squadron says:

        That makes sense. My thought was essentially that often times QALYs are incorporated into the Incremental Cost-Effectiveness Ratio (ICER). But I understand what you are saying in that the studies are not narrowly focused on quality/outcomes.

  8. Joey says:

    so this really freaked me out. I just signed up for the ACA and was approved for medicaid (through Humana). Do I have to worry about going to a primary care physician and not getting the same treatment as others? I’m 31, have high blood pressure and take paxil. What do I need to ask my future doctor to make sure I’m getting the best treatment that I can?! EESH! I’m so freaked out now!

  9. Badly Shaved Monkey says:

    As a Brit, I find the dispute over the ACA to be utterly incomprehensible. I think Dr G’s analysis explains why I am right to be confused. The main conclusions he has drawn are that the specific practical benefits and risks of the ACA are hard to quantify accurately and depend on a nuanced interpretation of complex data, that the point of principle is that expanding healthcare more widely to the poor is a reasonable ambition and the hoped-for benefits of the policy are supported at least to some degree by the data.

    There is simply no rational basis for the intensity of the vituperation directed at it from the Teapot fringe of American politics. The only reasonable conclusion that an outsider can draw is that the argument has nothing to do with any real effects of the ACA on the health of the American population.

    So, please can someone explain why the opposition is so fanatical that it would rather shut-down the US government and risk bringing down the economy through debt-default than allow this lawfully passed Act simply to progress into full operation? I suspect there are two answers: some publicly avowable point of alleged principle and a real underlying reason that depends on US pork-barrel politics.

    1. So, please can someone explain why the opposition is so fanatical

      Being one of the opposers, though hardly fanatical, I’ll explain:

      You live in a small town and have 2 neighbours
      - your neighbour on the right is William, an unemployed drug addict,
      - in the middle is you, a working class guy.
      - your neighbour on the left is Scott, a wealthy bank owner and drug dealer.

      Your small town parish collects tax from the 3 of you .. well no, actually just you, cause William doesnt have any money, and Scott doesnt declare any income and launders his cash in cayman island trust funds.

      The little tax revenue the parish receives from you is all spent on weapons to fight wars with a faraway parish somewhere in the persian gulf, social security payments to william, and the rest is handed out to Scott whose bank made some really bad bets in the horse racing circuit, and needed a bailout.

      The parish election is coming and the councillor needs William’s vote. He notes that William has no money to spend on drugs and frequently shows up at the local emergency room begging to get some oxycodone.

      An election proposal is made – lets setup a parish-wide narcotics insurance scheme so anyone in need of oxycodone can have it very cheap, and the parish will chip in for the bulk of the cost.

      There is a small problem with this plan – the parish is completely broke! All the tax money they got from you was spent on the war. Scott comes forward with a proposal – his bank will loan money to the parish at reasonable interest, his drug dealing business will supply the oxycodone,

      It wont matter really how you vote in the election, cause William already made up his mind and so did Scott, so the councillor secured himself a majority with or without you.

      Hope its a little more clear?

      1. weing says:

        I would just like to add that you are paying for the emergency room visits already anyway. With this scheme in place you may not need to borrow as much money from the drug dealer to pay him.

      2. mousethatroared says:

        hum…yeah, just so long as you’re not a fanatic. (LOL). Really, thanks, that was very illuminating.

      3. WilliamLawrenceUtridge says:

        Not really, it’s almost as if it’s a caricature of race and class relations in the US, as envisioned by a paranoid critic of the medical system.

        1. mousethatroared says:

          Yeah, exactly. that’s why it’s so illuminating.

          1. WilliamLawrenceUtridge says:

            The threading makes it harder to see, but I was replying to FBA’s “does that make it clear” :)

      4. Badly Shaved Monkey says:

        FBA

        Your incoherent “just so” story doesn’t really merit a detailed response. Its quality only serves to reinforce my conclusions about the ACA’s opponents.

        I note only that you failed to mention the possibility that someone might simply be poor and unfortunate. Your utter lack of compassion is well-reflected in your chosen pseudonym. One of the major criticisms of the American healthcare system is that the people working in it treat patients as revenue sources not human beings and those that are lucky enough to be able to afford good care adopt an “I’m all right, Jack” attitude, blithely ignoring the risk that one day they might fall through the bottom of the system. You are the embodiment of that.

        Are FBA’s the best arguments that the critics of the ACA can produce? Are there better arguments against the ACA that don’t simply reveal its opponents as heartless fuckwits?

        1. I note only that you failed to mention the possibility that someone might simply be poor and unfortunate.

          Sure, William in my story is poor and unfortunate. Did you miss the part where the state was completely broke?? It has no money to hand out. This is what the discussion is about.

          Do you think bankrupting the state will benefit the poor and unfortunates?

          You can ask Gorski how bankrupting the state benefits the healthcare of the unfortunate, coming from Detroit he should know all about it.

          1. Badly Shaved Monkey says:

            The current US system spends twice what other developed nations do and leaves the sick poor in a squalid state, which looks to the rest of us like bad economics and bad healthcare.

            But, I already found that discussing things with you is simply a waste of effort. My intention here was to explore whether the opponents of the ACA can produce any coherent arguments. So far, you confirm my conclusion that they cannot. I wonder whether you are typical.

          2. WilliamLawrenceUtridge says:

            Raise. Taxes.

            Other countries with dramatically lower GDP and smaller economies manage to provide health care, normally universal and of higher quality, while spending far, far less on a per-citizen basis.

            You can’t compare the US to the Greeks, who exploited a trick of the European Union banking system to buttress their terrible credit rating and borrow at low rates (and whose entire country is based on an underground economy that only taxes corporations; go on, try asking a Greek waiter for a receipt – you won’t get them, because they don’t give them out, because it means they get to keep all tip and tax. Even the tax collection system is so corrupt that tax collectors who actually collect taxes end up pulled from their jobs and assigned to desk work instead).

            Having a national health care system would also work against individual states having to manage on their own without assistance, which obviates against going bankrupt due to health care costs – and would also work on an individual level. How many citizens are forced to save money, removing it from the economy, in order to be able to pay for health care? How many state taxes must cover the expenses of patients who don’t come in until they collapse on the street, and must get treated at a more expensive stage of illness?

            Your country could learn something from the countries around it, and the Republicans could learn something from toddlers who do manage to share, rather than using it as an opportunity to desperately try to punish a successful candidate from the other party.

            You could learn something from a toddler, for instance, the belief that your fellow citizens are not merely made up of parasitic drug dealers and tax haveners, and thus are worthy of care.

          3. WLU: Raise. Taxes.

            That worked really well for Detroit didnt it? They raised taxes many many times. Income tax, new utility tax, gambling tax, tobacco and liquor tax, land tax. All that did was drive businesses out of town and turn the city into a Chernobyl-style ghost town. Thats what 50 years of democratic governors gets you – a bankrupt state.

            You can’t compare the US to the Greeks, who exploited a trick of the European Union banking system to buttress their terrible credit rating and borrow at low rates

            And USA is exploiting the reserve currency status of american dollar to buttress its inflated credit rating and borrow at low rates. Same result – out of control spending spree.

            Your country could learn something from the countries around it

            Like the country you are from? We are learning something allright, from Canadian doctors and Canadian patients who flee in horror. Waiting in queue 4 years for elective surgery? You do that.

          4. mousethatroared says:

            FBA”That worked really well for Detroit didnt it? They raised taxes many many times. Income tax, new utility tax, gambling tax, tobacco and liquor tax, land tax. All that did was drive businesses out of town and turn the city into a Chernobyl-style ghost town. Thats what 50 years of democratic governors gets you – a bankrupt state.”

            50 years Democratic Governors? Check your history.
            http://en.wikipedia.org/wiki/List_of_Governors_of_Michigan
            Your Detroit history is equally inaccurate.

          5. mousethatroared says:

            FBA “All that did was drive businesses out of town and turn the city into a Chernobyl-style ghost town. Thats what 50 years of democratic governors gets you – a bankrupt state.”

            Also, the State of Michigan is not bankrupt, the city of Detroit is. The major drivers of population flight in Detroit has never been blamed on higher taxes, because the majority of residence moved to the suburbs where most of the STATE taxes you are talking about are the same.

            Also, the State of Michigan is ranked #18 in the country by the Center for Tax Policy for pro-growth tax structures. That hardly indicates a huge tax burden for business, like you seem to suggest.

            You know, just checking your facts before jumping to any conclusions would increase the quality of your conclusions.

          6. David Gorski says:

            That worked really well for Detroit didnt it? They raised taxes many many times. Income tax, new utility tax, gambling tax, tobacco and liquor tax, land tax. All that did was drive businesses out of town and turn the city into a Chernobyl-style ghost town. Thats what 50 years of democratic governors gets you – a bankrupt state.

            Not exactly. It was much more complicated than that.

            http://www.freep.com/article/20130915/NEWS01/130801004/Detroit-Bankruptcy-history-1950-debt-pension-revenue

            http://www.freep.com/article/20130915/NEWS01/309150060/

            And, seriously. Over the last 50 years, Republicans have been governor a longer period of time than Democrats. William Milliken (a Republican) was governor from the late 1960s to the early 1980s, which is the period of time when the city declined the most. We currently have a Republican governor.

          7. WilliamLawrenceUtridge says:

            That worked really well for Detroit didnt it? They raised taxes many many times.

            Yes, well, that’s why it should be a national program, shouldn’t it? Spreads the moral hazard across more citizens, costing less in the process.

            Waiting in queue 4 years for elective surgery? You do that.

            Yes, Canada needs to improve it’s wait time for elective surgery.

            Do you have a comparable link for cancer treatment?

            And even the example you provide – it’s a variation of a two-tier system that allows us to take advantage of the proximity of a neighbour where, as long as you have the money, you can get faster treatment for elective surgery. Which means if you’ve got the money, you can get treatment right away. If you don’t, a spot just freed up.

            Read a book.

          8. David: And, seriously. Over the last 50 years, Republicans have been governor a longer period of time than Democrats.

            My bad, I was trying to say 50 years of democratic Mayors of Detroit, the governors of Michigan were a mixed crew.

          9. mousethatroared says:

            FBA “My bad, I was trying to say 50 years of democratic Mayors of Detroit, the governors of Michigan were a mixed crew.”

            While confusing city with state taxes as well.

            Hey! You know what other cities have had 50 years of Democratic Mayors? San Francisco and Boston (probably more…) yet somehow they seemed to avoid the same fate as Detroit.

            N=1 trials don’t work in politics either.

        2. mousethatroared says:

          Most of the coherent major criticism of the ACA that I’ve heard is that it falls far short of what we should have done, which is a single payer system.

          There is criticism that the act is overly complex. Well, yeah, see criticism that it’s not a single payer system.

          Almost all of the other major *criticisms I’ve heard on the ACA are based on misinformation put forth by the Replican party, Koch Bros and Fox.

          Here’s a link to the fact check on those http://www.factcheck.org/tag/obamacare/

          There is some concern over whether enough young people will sign up for the required health care insurance (they have the choice of taking a fine/fee instead) to optimize the economics of the system. Unfortunately, in attempt to attack the ACA at it’s weaker point the Koch brothers are funding two groteque commercials full of misinformation and targeted at young people, that encourage young people to not purchase insurance on the grounds that government will be controlling their healthcare. Regardless of the fact that the insurance that will be purchased is private insurance.

          (I would add, for a country that’s “broke” there’s certainly alot of money floating around to spend on adds and messaging.)

          That’s how it goes, if you can’t win with the truth and reason, try lies, emotional manipulation and sabatoge instead.

          *I’m sure there certainly valid criticisms of individual components of the act, unfortunately it’s hard to have discussions about fine tuning with all the hyperbole and misinformation floating around.

  10. mousethatroared says:

    WLU “As a foreign watcher of your extraordinarily interesting political process, I kinda hope this is the impetus that breaks the back of the current Republican party”

    Mostly it just makes me want to wallop a few specific older white guys upside the head.

    1. WilliamLawrenceUtridge says:

      Makes me wish the plagues of Egypt upon them.

      Old white guys do a markedly better job of improving health care when they are affected by it, lacking as they are the gland that produces “compassion”.

      1. mousethatroared says:

        …well, I don’t want to generalize. I know some very compassionate old white guys. Just these tea party folks. that bug me.

  11. Andrey Pavlov says:

    @WLU:

    I can’t seem to click “reply” under your name so I have to make this general comment. But you said:

    Raise. Taxes.

    Other countries with dramatically lower GDP and smaller economies manage to provide health care, normally universal and of higher quality, while spending far, far less on a per-citizen basis.

    I actually just demonstrated to a friend of mine that it is not at all necessary to raise taxes. We have plenty enough in taxation. Both as a percentage and as an absolute amount (thanks to our large population). In fact, Australia pays less taxes than we do unless you get out to the very extremes of income. It isn’t until around $400k annual income that Australian taxation actually matches ours, and their maximum rate of taxation is only 5.4% higher than our maximum rate of taxation (and you would have to break $1 million per annum to approach that rate).

    You can also look at economical analysis and see that while we do spend double as a percent GDP on healthcare than any other nation on the planet, some of that is actually justified since we would expect richer nations to spend more for less return on investment (basically, rich nations should be able to spend extra on perks that aren’t necessary but are nice). However, that only explains about 30% of the excess spending, which means that we are still spending roughly 70% more than we should based on the wealth of the nation.

    Another interesting fact that never seems to register for those against national health plans, the ACA, or general human compassion is that we already spend more money on health care in taxes than any other nation on the planet. Both as a percent and absolute amount. In other words, we as a people are paying for healthcare and not getting it.

    So no, we don’t need to actually raise taxes. We just need to spend our money wisely and increase transparency in costs. The common trope I face is that in order to have national healthcare we need to give up 80% (or some other outlandish number) in taxes to make it happen, which is simply false.

    1. WilliamLawrenceUtridge says:

      Well that just destroys FBA’s comment even more. I’ve never been so happy to be wrong :)

      You’re addressing my understanding of the strengths of a health care system as well – everyone pays a bit, and that means everyone gets care whenever they need it (because the second “everyone” is much lower than the first).

      And just because I like using the word, this comment is another ouroboros.

  12. weing says:

    “In other words, we as a people are paying for healthcare and not getting it.”
    We are also paying for government services and not getting them. Congress just voted to give back-pay to government employees for not coming in to work during the shutdown.

  13. Daniel Falcon says:

    Great post! What is the underlying evidence that acetominophen is even a useful pain reliever? It is well known as an anti-pyretic (fever reducer), but I submit it is a very poor medication for any substantial pain, in spite of the advertisements.

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