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The big Obamacare debate happening outside Washington: does insurance even work?

There is a central paradox that constantly shows up in the health care debate: Studies often find that giving people health care doesn’t always improve health in measurable ways. A new NBER working paper has reignited that debate, looking at the people who gained coverage from the Affordable Care Act.

In this case, the study authors set out to estimate the impact of the Affordable Care Act on a variety of outcomes, including access to health care, risky health behaviors (such as smoking and drinking), and how people thought about their health status.

They found that the ACA increased insurance coverage — by 5.3 percentage points in non-expansion states and 8.3 points in expansion states. The law also boosted the number of people who had a primary care doctor and checkups.

But that increased coverage didn’t translate to better health outcomes after two years. Following Obamacare, there were no detectable improvements in unhealthy behaviors and self-reported health in both expansion and non-expansion states. Although when they zoomed in on older adults under the age of 65, the ACA did seem to improve self-reported health for them, particularly in expansion states.

So why doesn’t giving people health insurance lead to better health? The evidence on this question is quite mixed — this study isn’t the first to find less-than-stellar health gains after people get insurance. I think there are at least five compelling explanations:

1) "Health insurance improves health for some people for some interventions but not for all people for all interventions." That's how NBER lead study author Charles Courtemanche summed up the literature. And I think he's right. Consider just one of the seminal studies on the impact of health insurance, which focused on Oregon's Medicaid expansion. The researchers found insurance improved people's access to care, made them less depressed, reduced their financial strain, and improved their perceptions of their health and well-being — but it didn't improve blood sugar control or their prevalence or diagnosis of high blood pressure or high cholesterol. It also didn't influence their use of medications for these conditions.

In the new NBER paper, one group — older adults — seemed to be healthier after the ACA. Courtemanche thought this was probably because they were sicker to begin with and needed the most care. When they got coverage, their health improved, unlike younger people who may not have had as many health conditions.

The University of Chicago’s Harold Pollack pointed out that the same is probably true for other groups living with conditions such as HIV. "Do we really believe insurance doesn't improve health when a third of the people in Illinois with HIV are brought on to insurance?" he said. "But that’s a small population, so it won't show up in an overall study."

2) The health system isn't great at addressing the chronic health issues that sicken people these days. So much of why we're unhealthy has to do with our behaviors and environments. We don’t eat healthy diets, we smoke too much, we don’t exercise, we live in communities that are polluted or unwalkable. These factors drive up the risk of cancers, diabetes, heart disease, and obesity — all among the top killers in America today.

Our health system came of age when the most pressing health problems people faced were infectious diseases, not these lifestyle-associated conditions. It wasn’t designed to tackle them, and it often doesn’t do a very good job on them. As the lead author on the Oregon study cited above, Katherine Baicker, told me: “There’s lots of evidence throughout the health care system that we don’t do a great job at managing chronic health conditions in general. And Medicaid doesn’t seem like the magic bullet on that.”

3) The studies we have may be too short-term to capture longer-term health benefits. Like many of the papers on the effects of health insurance, the new NBER study had a pretty short follow-up time — two years — and that may not be enough time to detect changes in health status, particularly for chronic conditions like diabetes and cancer. As Benjamin Sommers, a health economist and physician based at Harvard University, put it, "Coverage effects likely grow over time, and while this is a 'new' study, it’s not using newer data. It’s still only through the end of 2015, which is similar to what’s already out there."

4) Health insurance isn't the same as access to care, Kosali Simon, who has also studied the impact of insurance on health, told me. "[This is] because of the hurdles in navigating the health care system, or finding the best providers, or adhering to medical advice, and all the other factors that go into meaningful health improvements." Those are conditions that one's insurance status won't necessarily ameliorate — which also means health professionals need to find ways to make insurance a more powerful tool to improve health.

5) There may be limitations to the methods used to study health improvements with insurance. Many of the studies on the impact of health insurance rely on self-reported data (how people think about their health status) or administrative data (like medical claims to track costs and what services the newly insured might be using). But these methods may not be the best ways to measure health.

Anthem could exit Obamacare in 2018 — but maybe it's gamesmanship

In yet another sign that the uncertainty over the future of the Obamacare exchanges is disrupting the market, Bloomberg's Zachary Tracer reports that Anthem could be the next big insurer to abandon ship.

The loss of Anthem would be a huge blow for Americans on the exchanges in the 14 states where it sells coverage under the Blue Cross and Blue Shield brands. In Colorado, Kentucky, Missouri, and Ohio particularly, Americans could be left with no insurers as a result of the exit, Bloomberg reports. (To date, a third of US counties on have only one insurer, and there are 16 counties in Tennessee with no insurer at all after Humana pulled out of the marketplace.)

Anthem hasn't confirmed the decision (the story was based on analysts who met with the insurer), and this could also be a big bluff. As the Bloomberg story noted: "Anthem is in dialogue with the administration 'to emphasize the importance of regulatory and statutory changes in order to ensure sustainability and affordability of the individual market for consumers,' according to an emailed statement. The company continues to 'actively pursue policy changes that will help with market stabilization and achieve the common goal of making quality health care more affordable and accessible for all.'"

We asked Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management who has been studying the Obamacare exchanges, for his take. "This makes me think there might be a bit of gamesmanship here," he told us.

Chart of the Day


It's not just Bernie Sanders: Citing frustration over dealing with multiple insurance payers, nearly half of doctors say they'd want to move to a single-payer health system. The data came from a LinkedIn survey of doctors, which you can read more about here.

Kliff's Notes

With research help from Caitlin Davis

  • "Republicans Fuel Uncertainty Over Health Law’s Fate": “Mr. Trump and other Republicans have said they are optimistic that, out of the spotlight and without the pressure of deadlines, a health-care deal can be reached either through achieving a consensus between the party’s most conservative lawmakers and those from more centrist districts, or by reaching across the aisle to Democrats. But they have yet to identify specific areas where consensus is possible, and the talks in Washington aren’t being held at leadership levels. There also is scant evidence that the White House is seriously reaching out to Democrats to ease the pressure of passing a major bill on a party-line vote.” —Stephanie Armour, Kristina Peterson, and Louise Radnofsy, Wall Street Journal
  • "Kansas governor vetoes Medicaid expansion, leaving 150,000 poor residents uncovered": "This is, obviously, a huge setback for Medicaid expansion efforts — but the fight isn’t completely over. The Kansas legislature is likely to explore whether they can garner enough support to override the governor’s veto, which would require a two-thirds majority in both the House and the Senate." —Sarah Kliff, Vox

"Trump administration still plans to undo parts of the ACA, Tom Price testifies": “Under intense questioning from Democrats, Price outlined how his department could make insurance plans cheaper by scaling back several federal mandates, including what the ACA currently defines as 'essential benefits' in coverage. And he refused to say whether the administration will keep providing cost-sharing subsidies for insurers participating in the federal marketplace. The multibillion-dollar infusion is critical to maintaining the system’s stability, insurers say.” —Juliet Eilperin and Mike DeBonis, Washington Post

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