After sharing his agony over the Republican failure to
repeal and replace Obamacare—a broken promise if ever there was one—Ross Douthat
moves to a salient point. Has Obamacare made America healthier? Clearly, that
is what matters. The rest is noise. Sort of….
For our part we will note that the health care debate
also defines our national purpose. Are we a caring and nurturing nation or are
we a wealth generating nation? Are we more motherly or more fatherly. But it also
tells us that professing concern for the ill and wanting to treat them is
not the only or perhaps not even the most important factor when it comes to
health.
There is far more to good health than access to health care. And there is far more to good health care than having insurance.
Good personal habits have an important influence on whether we stay
healthy or fall ill. Moreover, if we look at the opioid crisis that has reached
epidemic proportions in many parts of the nation and if we examine the poor
health that white males, in particular, are suffering, we note that
these men are suffering for lack of gainful employment… not because of their
health insurance.
More emphasis on jobs will produce better health.
And yet, as Joe Biden announced yesterday, the 2016 Democratic presidential
candidate did not even mention jobs, except for the coal mining jobs she wanted to kill in West Virginia.
With that in mind we turn to Douthat’s argument. He intends
to shed some light into the darkness of the health care debate, and without
taking sides on this or that plan. His argument is, in the words of Nate
Silver, data-driven, not idea driven. The distinction matters, especially since
those who are caterwauling about facts are far more concerned about ideas.
Douthat notes that Republican lawmakers turned to “jelly” because
they were afraid of the PR campaign that would fill the airways with people who
were dying for lack of health insurance.
In his words:
One of
the most powerful arguments in the litany that turned moderate Republican
lawmakers to jelly was that they were voting to “make America sick again,” to
effectively kill people who relied on the Affordable Care Act for drugs and
surgery and treatment. Tens of thousands of people, Democrats warned, would die
if Paul Ryan’s stingy replacement took its place.
True enough the leftist propaganda machine will show us
endless images of children dying for lack of Medicaid. Of course, this will
happen no matter what reform the Republicans propose… assuming that they are
capable of agreeing on something.
Yet, the truth lies elsewhere:
… studies
going back decades that show little evidence that giving people insurance
actually makes them healthier.
To begin, Romneycare did provide benefits for the newly
insured, but Oregon’s Medicaid expansion showed no such benefits:
A study of
Mitt Romney’s Massachusetts insurance expansion showed health benefits for the
newly insured (most of whom got private insurance), but a study of
Oregon’s pre-Obamacare Medicaid expansion found that the recipients’ physical
health did not improve.
Since most of the new Obamacare insurance was provided
through Medicaid, the latter seems to be the more salient statistic:
Writing
in National Review during the brief repeal “debate,” Oren Cass argued that
since most of Obamacare’s insurance expansion was accomplished through
Medicaid, one would expect the new health care law’s impact on health to be
closer to what happened in Oregon than in Massachusetts. And indeed, despite
confident liberal expectations about how many lives Obamacare would save each
year, the only noticeable recent shift in the American mortality trend has gone
in the opposite direction — upward, likely thanks to the opioid epidemic.
Americans are sicker, not because of whether they do or do
not have access to Medicaid, but because they have been thrown out of work,
find their lives to be purposeless and get addicted to narcotics. Douthat does not mention the point, remarked by Tucker Carlson the
other night, that the problem with opioid abuse begins with the pharmaceutical
companies that are making a fortune over it and with physicians
who are writing an unconscionable number of prescriptions for these drugs. This
is not just a public health crisis. It is a physician generated crisis. One
might ask whether the Obamacare Medicaid expansion is paying for these opioids; one would be surprised to learn otherwise.
Statistics point in this direction:
Nor has
Obamacare’s Medicaid expansion been a bulwark against opioid-related misery. As
Cass points out, the mortality rates in states that expanded Medicaid rose
faster in 2015 than in the states that did not. This correlation also shows up
when you drill down in county-level data, as the pseudonymous blogger Spotted
Toad has shown: Overall, areas that have implemented the Affordable Care
Act in full have seen more deaths from drug overdoses than areas where the
Medicaid expansion didn’t take effect.
Douthat continues:
The
divergence in deaths between Medicaid and non-Medicaid counties started in
2010, and the full expansion went into effect in 2014, so it can’t be just that
Medicaid has made it easier for addicts to get painkillers. (The Spotted Toad analysis speculates
that an Obamacare provision that was implemented earlier, allowing
twentysomethings to stay on their parents’ health insurance plans, may also
have made opioid prescriptions easier to obtain.)
As for the bad habits that contribute to bad health,
Obamacare has not influenced them. This seems to explain why Obamacare has not
produced any notable improvement in public health.
Douthat writes:
And so
is a
new paper, just released through the National Bureau of Economic Research,
that tries to look at the Affordable Care Act in full. Its authors find, as you
would expect, a substantial increase in insurance coverage across the country.
What they don’t find is a clear relationship between that expansion and, again,
public health. The paper shows no change in unhealthy behaviors (in terms of
obesity, drinking and smoking) under Obamacare, and no statistically
significant improvement in self-reported health since the law went into effect.
(There is some improvement for older Americans in Medicaid expansion states,
but not for the population as a whole.)
Obviously, having insurance is not the same thing as having
access to health care. It tells us nothing about the quality of the healthcare
available to those who have Medicaid or to those who buy policies through the
exchanges. At best, Douthat remarks, it provides peace of mind. It’s not
nothing, but it’s not the same thing as health care or good health:
that
the bill was likely to provide its beneficiaries with more financial security
and greater peace of mind, but that it was not likely to be the sweeping
lifesaver that many of its most morally imperious advocates insisted that it
would be.
And also:
Security
and peace of mind are very good things, which is why voters like the Medicaid
expansion. The confidence that they don’t have to rely on the emergency room or
friends and family when they face an unexpected medical calamity is something
that Medicaid recipients would understandably prefer to keep.
Douthat does not address in detail the trade-offs produced
by Obamacare, but he notes that the program has had some influence on
employment, on how many people a company can hire and how many hours they can
work. Surely the example of France has shown that when it becomes too expensive—because
of different government mandates—to hire people companies do not do so.
Obamacare is
surely a step toward the welfare state that is crippling French employment. At the least, the constant talk about death
and dying obscures the fact that the Obama administration, through Obamacare
and through job-killing regulations has contributed to worse health and higher
mortality:
But the
health and mortality data is still important information for policy makers,
because it indicates that subsidies for health insurance are not a uniquely
death-defying and therefore sacrosanct form of social spending. Instead,
they’re more like other forms of redistribution, with costs and benefits that
have to be weighed against one another, and against other ways to design a
safety net. Subsidies for employer-provided coverage crowd out wages, Medicaid
coverage creates benefit cliffs and work disincentives, and there are other
possible interventions — direct cash support for work and family, above all —
that might make more of a difference to opportunity than funding a slightly
better health insurance plan.