Do Coverage Expansions Save Lives? ¯\_(ツ)_/¯

A few weeks after two studies called into question whether one particular element of Obamacare—its hospital readmissions program—may have increased mortality rates nationwide, another study released by several economists expressed doubt about whether the law’s more than $1 trillion in spending on coverage expansions actually reduced mortality. Moreover, the latest study also raises fundamental questions about whether any coverage expansion will generate measurable reductions in mortality rates.

Coming in a week when Democrats prepare to release the latest version of their single-payer legislation, which estimates suggest could cost at least $30 trillion, the study raises an obvious question: What exactly will Americans receive for all the trillions of dollars in new government spending the left proposes? The study basically shrugs.

Effects of Medicaid Expansion

The analysis showed the problems inherent with attributing changes in mortality rates to expansions in insurance coverage. The study noted that “if one simply compares the…difference in mortality rates for non-expansion versus full-expansion states…it would appear that Medicaid expansion has a large, immediate effect in reducing mortality.” But in reality, mortality rates among those two groups of states had begun to move in opposite directions before the main provisions of Obamacare took effect in 2014. “There is little additional divergence during 2014-2016.”

The researchers’ work highlights the inherent flaws in this field of study. Because mortality is by definition a rare event (particularly for younger populations), and because so many different factors affect mortality, it becomes exceedingly difficult to attribute any change in mortality rates to changes in insurance coverage.

For instance, the opioid crisis, which has led to a decrease in life expectancy, hit just before Obamacare’s coverage expansions took effect, and in many cases affected the same populations. This and other similar factors introduce statistical “noise” that make it difficult to conclude with any certainty that expanded coverage (as opposed to some other factor) impacted mortality rates.

Simulations Expose Flaws

In most cases, the “power analysis” simulations concluded that, to find a statistically significant reduction in mortality rates at least 80 percent of the time, the coverage expansions would have to reduce mortality by more than 100 percent—a statistically impossible result. Because Obamacare reduced the uninsured rate by only a few percentage points, and because most available data sets lack corresponding income and insurance information—to prove, for instance, that X person had Y type of insurance and Z income over a certain number of years—the researchers could not make conclusive assertions about coverage expansions’ effects on mortality.

As it is, the uninsured already receive significant amounts of health care. One 2017 study found they consume nearly 80 percent of the care used by Americans with health insurance. Therefore, to test the effects of coverage expansions on mortality, researchers either need an incredibly large increase in the number of insured individuals—tens of millions, if not hundreds of millions, of Americans—or much more precise data about the income and coverage sources of those who gain insurance.

Liberals’ Alarmist Rhetoric

The authors caution that “our analysis should not be interpreted as evidence that health insurance does not affect mortality or health, either overall or for particular diseases or subgroups.” (Emphasis original.) However, the analysis does demonstrate that health insurance likely has a small and difficult to quantify effect on mortality rates. The study therefore proves how liberal claims two years ago that Republican “repeal-and-replace” legislation would kill tens of thousands of individuals annually had little bearing in reality.

This post was originally published at The Federalist.

Did Obamacare Increase the National Death Rate?

Researchers have raised legitimate questions about whether a policy change included in Obamacare actually increased death levels nationwide.

Some may recall that two years ago, liberals engaged in no small amount of hyperbolic rhetoric insisting that repealing Obamacare would kill Americans. They viewed that fact as a virtual certainty, and spent more time arguing over precisely how many individuals would die under the law’s repeal.

About the Readmissions Program

The Obamacare change sparking the policy debate involves the law’s hospital readmissions program. Section 3025(a) of the law required the Department of Health and Human Services to reduce Medicare payments to hospitals with higher-than-average readmission rates. The program began in October 2012, and since October 2014 has reduced payments by 3 percent to hospitals with high readmission rates for three conditions: heart failure, heart attacks, and pneumonia.

The program intended to make hospitals more efficient, and encourage them to treat patients correctly the first time, rather than profiting on poor care by receiving additional payments for “repeat” visitors. However, several data points have called into question the effectiveness of the policy.

First, a recent article in the journal Health Affairs concluded that data proving the readmissions program’s effectiveness “appear to be illusory or overstated.” The study noted that, right before the readmissions program took effect, hospitals could increase the number of diagnoses in claims submitted to Medicare. After controlling for this difference, the Harvard researchers concluded that at least half of the “reduction” in readmissions came due to this change.

By contrast, a December study in the Journal of the American Medical Association found an even darker outcome. The JAMA study, which examined a total of 8.3 million hospitalizations both before and after the readmissions penalties took effect, found that the program “was significantly associated with an increase in 30-day postdischarge mortality after hospitalization for [heart failure] and pneumonia, but not for” heart attacks. This study suggests that, rather than incurring penalties for “excess” readmissions, hospitals instead chose to stop readmitting patients at all—and more patients died as a result.

Is This ‘Alarmist’ Rhetoric?

In a blog post analyzing the debate at the New England Journal of Medicine, former Obama administration budget director Peter Orszag pointed out the two studies arrive at conclusions that are likely mutually contradictory. After all, if the readmissions policy didn’t affect patient outcomes, as the Health Affairs analysis suggests, then it’s hard simultaneously to argue that it also increased patient mortality, as the JAMA paper concludes.

But Orszag also criticizes The New York Times for an “unduly alarmist” op-ed summarizing the JAMA researchers’ results. That article, titled “Did This Health Care Policy Do Harm?” included a subheading noting that “a well-intentioned program created by the Affordable Care Act may have led to patient deaths.”

  • Washington Post: “Repealing the Affordable Care Act Will Kill More than 43,000 People Annually”
  • Chicago Tribune: “Repealing Obamacare Will Kill More than 43,000 People a Year”
  • Vox: “Repealing Obamacare Could Kill More People Each Year than Gun Homicides”

These headlines don’t even take into consideration the comments from people like former Sen. Harry Reid (D-NV), who said, “If you get rid of Obamacare, people are going to die.” Then there were the “analyses” by organizations like the Center for American Progress, helpfully parroted by Sen. Bernie Sanders (I-VT), that said “getting rid of Obamacare is a death sentence.”

Alongside this rhetoric, the supposedly “alarmist” Times article seems tame by comparison. It didn’t use the word “Obamacare” at all, and it couched its conclusions as part of a “complex” and ongoing “debate.” But of course, the contrast between the mild rhetoric regarding hospital readmissions and the sky-is-falling tone surrounding Obamacare repeal has absolutely nothing to do with liberal media bias or anything. Right?

Democrats, the Science Deniers

The Times article concludes by “highlight[ing] a bigger issue: Why are policies that profoundly influence patient care not rigorously studied before widespread rollout?” It’s a good question that Democrats have few answers for.

Liberals like to caricature conservatives as “science deniers,” uninformed troglodytes who can barely stand upright, let alone form coherent policies. But the recent studies regarding Obamacare’s hospital readmissions policy shows that the Obama administration officials who created these policies didn’t have any clue what they were doing—or certainly didn’t know enough to implement a nationwide plan that they knew would work.

Given this implementation failure, and the staggering level of willful ignorance by the technocrats who would micro-manage our health care system, why on earth should we give them even more power, whether through a single-payer system or something very close to it? The very question answers itself.

This post was originally published at The Federalist.

Why Are We Expanding Medicaid…?

In a blog post this afternoon, the Washington Post’s Sarah Kliff has an interesting chart (reproduced below) about the health outcomes stemming from insurance coverage.  She included the chart in an attempt to rebut Governor Romney’s recent comments that uninsured patients can get care at emergency rooms.  But the REAL lesson from the chart below is the fact that Medicaid patients have virtually no improvement in survival times from patients who lack health insurance altogether.  Don’t believe me?  Take a look yourself…

That very, very narrow sliver between the green and red lines represents the health benefits of Medicaid.  According to the latest CBO estimates, Obamacare will spend $642 billion to bring this meager “benefit” to 11 million individuals.  Which brings me back to my original question: Why are we expanding this program again?

There They Go Again…

The liberal advocacy group Families USA is out with a “study” today purporting to tally the number of individuals who died due to a lack of health coverage from 2005 to 2010.  Today’s report extrapolates from a 2002 Institute of Medicine study that claimed about 18,000 individuals died due to lack of health insurance.

There’s just one problem with the IOM study – it has since been challenged and repudiated as inaccurate.  A 2009 paper by Richard Kronick – himself a former Clinton Administration official – included the following conclusions:

Adjusted for demographic, health status, and health behavior characteristics, the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer-sponsored group insurance at baseline….The Institute of Medicine’s estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect…There is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.

And it’s not just Kronick who agrees with this analysis.  Here’s Brookings Institution scholar, and noted liberal, Henry Aaron, in an interview with Politifact on the links (if any) between the uninsured and death totals:

“I found his reasoning compelling,” said Aaron, himself a member of the Institute of Medicine. “In fact, after listening to his presentation, I had a hard time believing that the IOM had done what they had done.”  In interviews, Aaron and other health care scholars agreed with Kronick that uninsured and insured Americans differ in many ways other than their insurance status.  “To estimate the impact of the lack of insurance on mortality rates, one has to control statistically for all of those differences,” Aaron said.  That, he added, is exactly what Kronick has sought to do so.

So an intellectually rigorous analysis by one Democrat – supported as being compelling and thoughtful by other Democrats – gets ignored by a partisan liberal interest group, because it would take away their likely pre-determined conclusion that Obamacare will reduce death rates.  As The Gipper himself stated, there they go again

Poorer Cancer Outcomes in Government-Run Systems

Wanted to pass along this article from the BBC about a new study of cancer treatment outcomes concluding that tens of thousands of individuals in Britain may be dying unnecessarily from cancer due to “delays in diagnosing cancer in the UK and poorer treatment after diagnosis” when compared to health care in the United States.  Patient advocate groups called for “giving older people fairer access to clinical trials and extending the upper age limits” where cancer screening services will be available for patients.

These disparities in treatment in the government-run National Health Service — where cancer treatments for older citizens are not widely adopted due to cost issues — are similar to those concerns raised by audience members at Wednesday night’s White House town hall.  In that forum, President Obama admitted he would opt-out of any government-imposed restrictions on health treatments when it came to HIS family — but individuals without the means to do so may have no such opportunity.