Alert (or at least health-care-obsessed) readers have no doubt been following the coverage of a new study on mortality in Massachusetts in the years following Romneycare's coverage expansion, the gist of which — the authors found a striking, Massachusetts-specific decline in death rates for the non-elderly — tends to confirm liberal assumptions about the benefits of health insurance, and undercut the conservative and libertarian argument that insurance doesn't have the impact on health and mortality that most people expect. The study's findings are an almost-diametrical reversal of the results from Oregon's Medicaid experiment, which were much discussed around this time last year (here's my contribution), and which seemed to strengthen the conservative critique of Obamacare's pursuit of comprehensive coverage. So now it's liberalism's turn to claim vindication, and to press Obamacare's critics to give ground in the debate.
And some ground-giving is appropriate. Megan McArdle, among right-of-center writers, has probably written most extensively on the insurance-and-health question, so I think her response to the new study deserves to be quoted at length:
… here's my basic take: The study looks pretty good. It is hard to reconcile these results with Oregon. Good Bayesians will update their beliefs accordingly.
… I can think of reasons to believe Oregon rather than Massachusetts: It's a real [randomized controlled trial], rather than a comparison of counties that are supposed to be similar but might not actually have been in practice. There are surprising results that might be red flags about the data: For instance, cancer mortality dropped, even though the study only ran four years. If the benefit is coming from early detection, I would expect it to take longer to have a significant impact on the data … Massachusetts also has differently sized samples — the control group has about 10 times the population of the treatment group. Since larger groups should tend to have less variance, this might increase the odds of getting a surprisingly good or surprisingly bad result with your treatment group.
Most worrying is the period they compared: 2007 to 2010 … The authors are not stupid; they control for unemployment and poverty. But if the financial crisis affected Massachusetts differently from the rest of the country — and it did — then that may well show up in mortality in ways that are hard to measure.
That said, I can also think of reasons to believe Massachusetts over Oregon. The treatment group sample is smaller than the control group by quite a lot, but it's still huge by comparison with Oregon: 3,900,000 rather than around 6,000. And Massachusetts is a single comprehensive system, unlike Medicaid, which people might drop in and out of as their income changes, dampening the effect of insurance. The authors find mortality that's amenable to treatment dropping more rapidly than overall mortality. And comparisons with nearby counties, and with the state's elderly population, also deliver the same result.
So what should we believe? I haven't changed my beliefs radically: I still basically think that health insurance improves mortality rates, but that that improvement is unlikely to be huge if you can get results like Oregon. However, after yesterday's report, I've revised the probability of "huge benefits" upward, and you should do the same. And beware of those who are only willing to revise their beliefs in one direction.
I completely agree, and I would only add the following point: To the extent that we should revise up the potential health benefits of insurance, we should revise down the extent to which the most rigorous conservative alternative to Obamacare — a reform that would shift the system toward flat, universal subsidies for catastrophic coverage — represents a kind of public policy free (or at least relatively-inexpensive) lunch. That is, if the preponderance of the evidence suggests that insurance's health benefits are relatively limited, policymakers can hope to reap the cost-containing benefits of bigger co-pays and higher deductibles and health savings accounts without worrying too much that they're creating gaping chasms between the care people need and the care they can afford and get. But if the Massachusetts study, rather than the Medicaid data or the famous RAND health insurance experiment, gets closer to the typical reality o f what a health insurance expansion does, then policymakers are faced with a more explicit trade-off, in which what's saved through market forces by giving people more responsibility for their own health spending has to be balanced against what's lost in foregone care and treatment. And while having that trade-off suddenly look a lot starker than it has to date wouldn't settle the overall debate, it would give liberals a stronger case for their approach.
As I noted in an earlier post, the mortality issue is one of several plausible metrics for assessing whether Obamacare succeeds or disappoints, and because of the variance in coverage expansions between red and blue states, presumably researchers will be able to push further on this question over the next five or ten years, and the evidence on one side or the other will look more dispositive. Right now, I would only offer a word of caution for liberals, who are (understandably) folding this study together with other positive data points (falling uninsured numbers in Gallup's polling, a brighter deficit picture, good news on some specific policy targets) to make a case that the empirically-driven conservative critique of Obamacare is in the early stages of collapse.
For all we know it might be, but the reality is that on most questions — mortality, deficits, cost containment, and coverage — we are by definition years away from remotely dispositive assessments. The Massachusetts research is only significant because the authors had years of post-Romney data to examine; going forward, on just about every metric that matters for Obamacare, we're looking at a similar timeframe for meaningful numbers and outcomes and results. So if either side, on any of these issues, is going to need to give substantial ground, the only intellectually-responsible way to do it will be … slowly.
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