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.
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.
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.
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.