What happens when you give poor people health insurance?

July 11, 2011 6:50 AM

The Oregon Health Insurance Experiment: Evidence from the First Year (or, What Happens When You Give Poor People Health Insurance?) "We find that in this first year, the treatment group had substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations), lower out-of-pocket medical expenditures and medical debt (including fewer bills sent to collection), and better self-reported physical and mental health than the control group."

See also: The Doctor Might See You Now: The Supply Side Effects of Public Health Insurance Expansions. "This study finds that following the implementation of the State Children’s Health Insurance Program, physicians decreased the number of hours spent with patients, but increased their participation in the expanded program. Suggestive evidence is found that this decrease in hours was a result of shorter office visits."

Lots of other interesting papers at the National Bureau of Economic Research.

posted by OmieWise (65 comments total)

An article about the paper at the NYTimes.
posted by OmieWise at 6:51 AM on July 11, 2011

I'm going to take bets on how much the response will be some flavor of : This will just encourage people to be poor!
posted by The Whelk at 6:53 AM on July 11, 2011 [6 favorites]

They had to hold a lottery so that people could get heath insurance coverage.
posted by sinnesloeschen at 7:00 AM on July 11, 2011 [7 favorites]

This just in...People will use health care if you make it available and affordable.
posted by Thorzdad at 7:02 AM on July 11, 2011 [17 favorites]

Er, is there anything to that main link except an offer to buy the paper for five bucks?
posted by griphus at 7:03 AM on July 11, 2011

Yes, but how many of our veterans didn't slog through the swamps in VietnamIraq to see this once-great country turn pink-o?
posted by DU at 7:03 AM on July 11, 2011 [2 favorites]

(Or the second link for that matter?)
posted by griphus at 7:04 AM on July 11, 2011

I have a good friend who won this particular lottery, in Oregon. He's a barista first, and a par time web designer second. He doesn't make much cash, and could never afford health insurance on his own.

However, he does deal with some pretty intense mental health issues, and because of this insurance, he was able to stay out of the ER 3-4 times a year, and start taking meds and getting some therapy. No more (expensive) ER stays.

I really wish i lived in a place where this was common sense.
posted by furnace.heart at 7:05 AM on July 11, 2011 [13 favorites]

... the treatment group had ... higher health care utilization ... lower out-of-pocket medical expenditures ... and better self-reported physical and mental health than the control group.

I find it funny (read: sad, annoying) how conservatives argue that the uninsured have adequate access to health care in the form of the emergency room. Inconsistent + expensive + ineffective ≠ adequate.
posted by troll at 7:06 AM on July 11, 2011 [3 favorites]

*Health insurance

Although I wonder what exactly 'heath insurance' would constitute?
posted by sinnesloeschen at 7:09 AM on July 11, 2011

Although I wonder what exactly 'heath insurance' would constitute?

Having been on Medicaid until recently, it's amazing. Better than any private insurance I've ever had, and I'm a dude who has to go to the doctor constantly.
posted by griphus at 7:11 AM on July 11, 2011 [2 favorites]

Yes, but this ignores the real question: how much money did the drug and insurance companies make this quarter in the region?
posted by absalom at 7:11 AM on July 11, 2011 [3 favorites]

Researchers were unable to detect a change in emergency room use.

Seems kind of odd that despite all the preventive care the newly insured were getting and how much better they felt and reported their health to be, it didn't seem to affect this. One of the basic lines of argument has always been that if people could just get insurance, it would cut down on the wasteful "I have a headache, I'll go to the ER" sorts of visits that society ends up (over)paying for.
posted by Etrigan at 7:12 AM on July 11, 2011

griphus, you (and others) might be interested in the Slate article about this, along with the NYT one.

I will say that I found the summing up of the study confusing: were they studying those who were motivated to finish their paperwork (the Slate article notes only about 30% of the lottery winners ever made it to getting insurance) or were they studying all the winners, including those who weren't motivated enough to jump through that many hoops? I'll have to look at the NYT article and see if they make it clearer.
posted by librarylis at 7:16 AM on July 11, 2011 [1 favorite]

We don't care how healthy or happy they are, we just need them for cheap labor.
posted by Legomancer at 7:20 AM on July 11, 2011 [2 favorites]

Yeah, that's great and all but they're poor!
posted by tittergrrl at 7:20 AM on July 11, 2011

From the NY Times article:

While the findings may seem obvious, health economists and policy makers have long questioned whether it would make any difference to provide health insurance to poor people.

This should speak volumes about where our society is.
posted by weinbot at 7:21 AM on July 11, 2011 [29 favorites]

We don't care how healthy or happy they are, we just need them for cheap labor.

With the new unemployment numbers I don't think they need them for anything, really.
posted by The Whelk at 7:25 AM on July 11, 2011 [2 favorites]

We don't care how healthy or happy they are, we just need them for cheap labor.

The first AI to awaken will be a god on Earth.

The second through ten millionth will be slaves for at least 300 years.
posted by DU at 7:26 AM on July 11, 2011

but but but socialism increased eleven bazillionty percent!
posted by deadmessenger at 7:27 AM on July 11, 2011 [2 favorites]

"... then they'd better do it and decrease the surplus population!"
posted by seanmpuckett at 7:29 AM on July 11, 2011

Er, is there anything to that main link except an offer to buy the paper for five bucks?

Both papers download as free pdf's for me. I don't think I'm behind a proxy that would change that behavior for other people. I see no mention of paying anything anywhere on either page.

Is anyone else having trouble?
posted by OmieWise at 7:32 AM on July 11, 2011

They had to hold a lottery so that people could get heath insurance coverage.

The morning of June 27th was clear and sunny, with the fresh warmth of a full-summer day; the flowers were blossoming profusely and the grass was richly green. The people of Oregon began to gather in the squares, between the post offices and the banks, around ten o'clock; in some states there were so many people that the lottery took two days and had to be started on June 26th, but in this state, where there were less than four million people, the whole lottery took less than two hours, so it could begin at ten o'clock in the morning and still be through in time to allow Oregonians to get home for noon dinner.
posted by dersins at 7:34 AM on July 11, 2011 [13 favorites]

How many Americans have to die before your countrymen realize that single payer provides better outcomes at a lower cost?
posted by blue_beetle at 7:35 AM on July 11, 2011 [1 favorite]

How many Americans have to die before your countrymen realize that single payer provides better outcomes at a lower cost?

Honestly? A lot more. That is not right or fair or sane, but it is the correct answer.
posted by Brandon Blatcher at 7:36 AM on July 11, 2011 [16 favorites]

Yes, blue_beetle, but that doesn't sound very profitable to me. What would the shareholders think?
posted by Ghostride The Whip at 7:36 AM on July 11, 2011

Milton Friedman: "Everybody is spending everybody else's money, and nobody spends somebody else's money as carefully as he spends his own. Why should people have to get their medical care in that way? Why shouldn't they be able to arrange for it themselves? Why shouldn't they be able to pay for it directly? The problem really resolves itself into catastrophe versus ordinary. With respect to ordinary medical care expenses, they are relatively modest; there is no reason why people can't pay for it on their own."

That viewpoint is all that matters to the Republicans. Clear and simple.
posted by blucevalo at 7:39 AM on July 11, 2011

Thorzdad is right. People with health insurance pay less out of pocket, go to the doctor more frequently, and are healthier than people without health insurance? Who exactly should be surprised by this?
posted by xbonesgt at 7:42 AM on July 11, 2011

OmieWise, both main links are (short!) abstracts with details about purchase of full articles for $5 for me.

Emergency care is not healthcare.
posted by peacay at 7:44 AM on July 11, 2011

People with health insurance pay less out of pocket, go to the doctor more frequently, and are healthier than people without health insurance?

And some Republican had to pay for it, somehow. STOP SOCIALISM IN AMERICA.
posted by Brandon Blatcher at 7:47 AM on July 11, 2011

OmieWise, both main links are (short!) abstracts with details about purchase of full articles for $5 for me.

Well, that's embarrassing. I hate firewalled content in posts. Anyone interested in the full papers is welcome to MeMail me.
posted by OmieWise at 7:49 AM on July 11, 2011

When "better outcomes" has any hint of "My money doesn't get me the best care immediately", "I'm paying for someone else to get health care", "Someone who is not working or even trying to find work still gets health care", or scariest of all, "This ethnic person who has spent time in jail for selling drugs gets to visit the doctor and get medication for an illness I can't physically see while I have waited for TEN MINUTES TO SEE MY DOCTOR AND MY WAY TOO HIGH TAXES ARE PAYING FOR THIS!" then we will have vicious outrage at the concept of single-payer health care.

Most of these people are either in a group that would greatly benefit from such a system due to their own health plans being insufficient or nonexistent, a group that would greatly benefit due to no longer needing to pay for a company insurance policy and thus their business would be more profitable, or a group which would benefit greatly from a system which covers everybody and reduces waiting times since they wait far too long to see a doctor who still accepts Medicare.

Doesn't matter. Their solution to rising hospital costs and wait times would likely be more along the lines of refusing care for the indigent even at the ER. No insurance? Bad credit score? Bleed to death on the sidewalk, we'll take what's in your wallet to cover the cost of hauling your corpse away.

Personally, I'm skeptical about national health care for a number of reasons, not least of which the tendency for certain interests to lobby for gutting it in a way that it benefits them (Our piss-poor excuse of an insurance bill that's coming to pass) yet if there's a robust plan which clearly reduces costs and improves services all around, I'm for it. I am all for it. If nothing else, cover preventative care for everyone. Even if the rationale is to cut back on sick days for our relentless drive for productivity, may we find the sanity necessary to do the things that we know and are proving will work.
posted by Saydur at 7:49 AM on July 11, 2011

On the one hand I am glad that those of us who support universal access to health care have the information from this study as one more piece of evidence to point to to support the argument that getting more people better health care access not only makes those people healthier but also can save communities money in the long term by preventing debt defaults, increasing worker productivity and reducing the rate of chronic disease.

On the other hand, what does it say about the country I live in that the question of whether having access to basic medical care makes people healthier is still in dispute? What does it say about us that we continue to dither on this question while tens thousands of our citizens die unnecessarily each year specifically because they couldn't afford health insurance?

Next I bet some state is going to set up a lottery to decide which people who can't afford food will get food aid, and then the National Bureau of Economic Research can do a helpful study on what happens when only some people have access to food.
posted by BlueJae at 7:50 AM on July 11, 2011 [6 favorites]

...set up a lottery to decide which people who can't afford food will get food aid.

As far as I'm aware but as far as I know, it is considerably easier to get on SNAP/WIC/TANF than it is to get Medicaid. I could be wrong, though.
posted by griphus at 7:56 AM on July 11, 2011

"As far as I'm aware but as far as I know" indeed. Sigh.
posted by griphus at 7:56 AM on July 11, 2011

‘What we’ve learned is Medicaid matters’ - Ezra Klein.
posted by peacay at 8:04 AM on July 11, 2011

It's interesting that in the UK the emotion associated with the NHS is generally pride. Wonder how the US could get to a position where it's a source of national pride that you've got each other's backs, at least somewhat.
posted by Leon at 8:07 AM on July 11, 2011 [1 favorite]

It's interesting that in the UK the emotion associated with the NHS is generally pride

I am speaking as a UK person: hell yes, I'm proud of the NHS.
posted by jaduncan at 8:11 AM on July 11, 2011

I really wish i lived in a place where this was common sense.

You mean like every other G20 country except the US?

It's interesting that in the UK the emotion associated with the NHS is generally pride. Wonder how the US could get to a position where it's a source of national pride that you've got each other's backs, at least somewhat.

Until the poor stop seeing themselves as temporarily embarrassed millionaires you're screwed.
posted by Talez at 8:12 AM on July 11, 2011 [3 favorites]

It's interesting that in the UK the emotion associated with the NHS is generally pride

It would be a neat trick to switch the narrative in the US in such a way that it became a huge nationalistic source of pride that we helped our poor better than any other country. Figure out some way to tie it in to Christian ideals and make it a get a sort of jingoistic us versus the rest of the of the world competitiveness into it, and you'd pull off the weirdest humanitarian coup of all time.

Quick! Someone figure out how to make this happen!
posted by quin at 8:24 AM on July 11, 2011 [3 favorites]

Figure out some way to tie it in to Christian ideals...

The problem is overriding the QED of "to be a good person, you have to work hard" and "if you're poor, you haven't been working hard enough."
posted by griphus at 8:27 AM on July 11, 2011 [1 favorite]

Way more likely are social support networks requiring religious affiliation or membership.

The only free Americans hate before then the poor is the idea that they might be getting a free ride.
posted by The Whelk at 8:27 AM on July 11, 2011

The idea of more widespread medicare/medicaid type plans scares the holy hell out everyone on the business strategy side of providing healthcare. Not because they're greedy, but because everything is already running on a very thin margin.

The whole system is propped up by a few private payors covering losses associated with medicare and medicaid (and the big non-profits to a certain degree). People bitch and moan about the possibility of paying for other people's healthcare, but they already are in the least efficient way imaginable with every one of the thousands of payors individually negotiating reimbursements with providers. CMS sets non-negotiable impossibly low reimbursements and private individuals and health insurers are stuck with the tab, in such a way that the smaller you are, the more you pay.

There are no good trend lines in healthcare. The economy sucks, income gaps are growing, people are aging out of private insurance and into an *expensive* cohort, supply is tightly constrained, etc. At some point, private health insurance gets so expensive (to cover an increasingly large pool of patients that lose money) that nobody can afford it and then what?

Without some type of demand management (call it what you like) the whole thing is going to fall apart. People will consume as much healthcare as they can (whether or not it's necessary) and as a society we just don't have the money to pay for it.

And yeah, single payor health care would be awesome, but I don't think many people have even the foggiest idea what that would (will?) involve. Hell, how many people in this educated audience can even say who cuts the paycheck their doctor receives every month? Even if we all desperately wanted the same thing, the system is so complex and so variable and so entrenched that it's unimaginable that we could fix it without killing it first.

I'm not able to made a coherent argument right now. I just stopped by to say everything is going to fall apart and we're doomed.
posted by pjaust at 8:42 AM on July 11, 2011 [3 favorites]

I'm sure the Robert's Court will be along shortly to put a stop to this whole "poor people getting health care" thing.
posted by T.D. Strange at 8:45 AM on July 11, 2011

MetaFilter: Everything is going to fall apart and we're doomed.
posted by Zozo at 8:49 AM on July 11, 2011 [3 favorites]

Metafilter: I'm not able to made a coherent argument right now.
posted by Leon at 8:52 AM on July 11, 2011

Maybe this ties into the whole "poor Americans see themselves as temporarily embarrassed millionaires" thing. So they see all these other temporarily embarrassed millionaires in need of healthcare and think "fuck off, I'm not paying for their healthcare, they're millionaires! They can pay for it themselves!".
posted by EndsOfInvention at 9:06 AM on July 11, 2011

I'm sure the Robert's Court will be along shortly to put a stop to this whole "poor people getting health care" thing.

Things like this make me hope for an untimely, tragic death to any of Thomas, Scalia, Alito or Roberts. Any day now...
posted by Mister Fabulous at 9:17 AM on July 11, 2011

Even if we all desperately wanted the same thing, the system is so complex and so variable and so entrenched that it's unimaginable that we could fix it without killing it first.

Is it bad that my first thought on reading this was "Then kill it."?
posted by CrystalDave at 10:01 AM on July 11, 2011 [3 favorites]

I just wonder what it is like to be a part of the control group in studies like this.

"Well, you didn't win the lottery for health insurance, but please let us know how many medical bills you have that you can't pay, how often the debt collectors harass you, and how depressed you are."
posted by Quonab at 10:03 AM on July 11, 2011 [1 favorite]

pjaust: "The idea of more widespread medicare/medicaid type plans scares the holy hell out everyone on the business strategy side of providing healthcare. Not because they're greedy, but because everything is already running on a very thin margin.

I read the US has far and away the highest spending on healthcare, yet doesn't have far and away the healthiest people. It seems to me there's a very wide margin somewhere.

Single payer will certainly put a lot of insurance brokers, intentionally shitty claims reimbursement software designers, and billing agents out of work. As a compromise, how about we train them to do something productive. Something useful to the world, maybe something like health care.
posted by pwnguin at 10:39 AM on July 11, 2011

One of the basic lines of argument has always been that if people could just get insurance, it would cut down on the wasteful "I have a headache, I'll go to the ER" sorts of visits that society ends up (over)paying for.

Well, up here in Soviet Canuckistan, where health insurance is widely available to citizens all across this great land, people will still go to the emergency room if they have the sniffles. So yeah, having free health insurance isn't going to stop people from going to the emergency room for stupid things.
posted by antifuse at 10:45 AM on July 11, 2011

I'm really pleased to see this in the Blue as my wife has worked on this study for several years. Lots of hard work, smart folks, and heartbreaking stories are behind all of this research. Please smack me in the head with a brick if I ever complain about access to Dental Care, Health Care and public transportation again.
posted by TomSophieIvy at 11:02 AM on July 11, 2011

Usually posts on "Not Always Right" make me laugh. This one from earlier just made me sad...

(I work for a call center for the state’s health insurance.)

Me: “Thank you for calling. How may I help you?”

Member: “Hi, I’m calling to make sure my husband’s heath insurance is active.”

Me: “Okay, do you have his ID number or social?”

Member: “Well, no. I’m not sure where his card is and I don’t know his social by heart.”

Me: “Well, is he there with you? I could get it from him.”

Member: “He is, but he can’t really talk right now. He’s having a heart attack.”

Me: “Ma’am, you need to call 911 right now, not us.”

Member: “I will. I just want to make sure he’ll be covered when they take him to the hospital!”

I know we're supposed to laugh at the silly customer. And yet... why is this even a question?
posted by Karmakaze at 11:15 AM on July 11, 2011 [2 favorites]

Wait, we're using the poor to test the efficiency of social health and wellness programs?

I'm pretty sure the only response you'll get from Speaker Boehner is, "Continue testing."
posted by Slackermagee at 11:43 AM on July 11, 2011 [1 favorite]

Well, that's embarrassing. I hate firewalled content in posts. Anyone interested in the full papers is welcome to MeMail me.

If you google the article title, a pdf pre-print is the third link. To answer a common question, the analysis is as-randomized, but they use a technique called instrumental variables to re-inflate the effect size for people who didn't take the insurance up. Notably, applying that conclusion to everybody assumes that the effect in the people who took the medicaid is the same as those who didn't.
posted by a robot made out of meat at 12:04 PM on July 11, 2011

I just wonder what it is like to be a part of the control group in studies like this.

An awful lot like being any other American, I suspect.
posted by dersins at 12:06 PM on July 11, 2011

On the other hand, what does it say about the country I live in that the question of whether having access to basic medical care makes people healthier is still in dispute?

Eh, the evidence has been surprisingly ambivalent on this point. It's easy to forget in an era of Gleevec and other miracle drugs but the successful treatment (read: survival) of people with cancer and heart attacks and strokes and all the other stuff that is likely to kill us is a comparative recent phenomenon. Hospitals used to be where you'd go to die, full stop. Sixty-some odd years ago the leader of the free world died of hypertension--something considered eminently treatable for pennies a day today--because the top cardiologists in the country couldn't prescribe much more than rest. Fast-forward to the introduction of Medicare (single-payer healthcare for the elderly) in 1965, and you still don't see much of an effect of expanding health insurance to previously-uninsured people**--in fact, Amy Finkelstein, the lead author of the article in the FPP, did a study about 5 years ago that showed introducing Medicare had basically no effect on elderly mortality. (At least in the short term. Long-term, I'd argue insuring nearly all elderly Americans with insurance was a huge spur in developing effective treatments for things like heart disease and cancer that tend to afflict the elderly.) Health insurance doesn't mean much unless it ensures access to quality care that can actual reduce mortality and morbidity, and that hasn't been much of a sure thing for many (most?) conditions until the past few decades.

Anyway. Kind of a random digression, but other than the obvious political fodder, there's a reason a lot of people are excited about this study; it's incredibly hard to estimate what sort of effect health insurance has because those who are motivated to sign up for it tend to differ in important ways, so you often end up in a situation where data shows that those with insurance are much less healthy than the uninsured.


**Kind of interesting side note: Medicare did have an effect on the mortality of non-white children, though this group wasn't actually granted insurance through the program. Many previously-segregated hospitals in the South decided to desegregate in order to become eligible to treat Medicare beneficiaries, and this desegregation was linked to a decline in childrens' deaths from preventable causes like diarrhea and pneumonia.
posted by iminurmefi at 12:54 PM on July 11, 2011 [2 favorites]

Member: “He is, but he can’t really talk right now. He’s having a heart attack.”
Me: “Ma’am, you need to call 911 right now, not us.”
Member: “I will. I just want to make sure he’ll be covered when they take him to the hospital!”

I suspect this sort of thing happens more often than one might suspect. While I've not had a heart attack, I know know I've injured myself a few times where the prudent action would have been to head to the ER, but I opted not to go because of the high deductible on my insurance.

Remember, kids..."Covered" ≠ "Will pay for".
posted by Thorzdad at 2:26 PM on July 11, 2011 [1 favorite]

Without some type of demand management (call it what you like) the whole thing is going to fall apart. People will consume as much healthcare as they can (whether or not it's necessary) and as a society we just don't have the money to pay for it.

This is simply untrue, as demonstrated out by the numerous other countries that have sucessfully implemented and run socialised healthcare.

People consume as much healthcare as they need - no one likes going to the doctor, and people will do not do it frivolously.
posted by His thoughts were red thoughts at 5:21 PM on July 11, 2011

Like oh, sure, we need to study this. We can't learn anything from the decades of experience of the UK or Canada. Because the health needs of Americans are exceptional.

I don't need studies to know that people who get health care live longer on average. Or that societies that poison their environment tend to be unhealthy. All this 'discussion' falls into the FUD bin.
posted by Twang at 6:06 PM on July 11, 2011 [1 favorite]

seriously, this study is very much my thing, but it was just too obvious for me to have to do it.
posted by skepticallypleased at 7:50 PM on July 11, 2011

People consume as much healthcare as they need - no one likes going to the doctor, and people will do not do it frivolously.

NHS has lots of coverage decisions they make, which explicitly take into account costs given a finite budget. Various Canadian provinces have services and procedures which are unavailable or have long waits (which is a function of not spending money on those services). The US is at 17.6% of GDP and declines lots of services. Costs can go as high as you'll let them.
posted by a robot made out of meat at 6:18 AM on July 12, 2011

People consume as much healthcare as they need - no one likes going to the doctor, and people will do not do it frivolously.

Not strictly true - as I mentioned above, Ontario still suffers from far too many people going to the ER when they have the sniffles. Not sure how severe it is, but it's severe enough that I recall talk of implementing a minimal (like, $10) "ER fee" to encourage people to wait and go see their own doctor instead (or go to a walk-in clinic).
posted by antifuse at 6:46 AM on July 12, 2011

It's interesting that in the UK the emotion associated with the NHS is generally pride. Wonder how the US could get to a position where it's a source of national pride that you've got each other's backs, at least somewhat.

Here's an American's (and MeFite's) tale of his recent experience with the NHS: An Eye-Opening Adventure in Socialized Medicine
posted by homunculus at 9:21 AM on July 17, 2011