By Matthew DeCamp, MD, PhD


Advocates of Medicaid expansion seemingly experienced a setback this week.  A study in the New England Journal of Medicine (NEJM) casts doubt on whether increased access to Medicaid results in better health outcomes, and media on both sides of the aisle have been quick to spin the results.  Does the study ‘shatter liberal health care claims’?  Were the mental health outcomes astoundingly positive?  Or is it simply an opportunity to take ideological advantage?


From a bioethics perspective, the answer may be none of the above.  Instead the study and its response serve as a reminder: Facts seldom speak for themselves, and clarifying the values at stake in a policy debate can be critical to translating facts into policy-relevant conclusions.


In the study, individuals eligible for Oregon’s Medicaid program, the Health Plan Standard, were selected by lottery in 2008 to come off a waiting list and given the opportunity to enroll in the plan. Over the next two years, researchers followed individuals who gained access to the plan and compared their health outcomes, financial burdens and perceived quality of life.  Some public health experts lamented the necessity and permissibility of such a study, which only seems possible in countries where access to health care is not assured to all citizens.  All things considered, however, the rigorous study design and its conduct allow evaluation of this harsh reality.


On one hand, the researchers found that individuals selected in the lottery to gain access to Medicaid reported decreased financial strain, perceived their health as improved and experienced less depression.  They also gained access to health care, and as a result utilization (and hence cost) increased compared to the control group.  On the other hand, Medicaid access did not improve the diagnosis or control of high blood pressure or high cholesterol, nor increase the use of medications to treat these conditions and did not result in improved control of diabetes.  In other words, aside from depression, access to Medicaid did not improve these “hard” health outcomes.


So is access to health insurance – in this case, Medicaid in Oregon –good for you?


Advocates of expansion will no doubt answer the question affirmatively and be quick to point out the study’s limitations.  As the authors themselves note, the study was limited by including a relatively small number of individuals with high blood pressure, high cholesterol and diabetes, and by its short duration. As a result, some clinically-significant changes (for example, improved control of diabetes) were not statistically significant, even though they were in the positive direction. Many clinicians might consider the average period of coverage (17 months) as short for achieving meaningful control of diabetes.   An accompanying editorial in NEJM similarly points out the limited number of important outcomes, which did not include early cancer detection, and the complex socioeconomic factors that influence health outside of basic access to care, which were beyond the study’s scope.


Such important details become lost in debate over Medicaid expansion.  More importantly, focusing on them diverts attention from what is undoubtedly contributing to the disagreement: fundamental differences in ethical values.


For example, deciding whether to focus on so-called hard outcomes (such as cholesterol levels) rather than improved quality of life is not just a question of fact.  It is also one of competing ethical values. How do we value and weigh perceived life quality?  Is this value incommensurable with health outcomes and cost? To translate these data into policy requires a judgment about ethical values – both which ones to include in the decision, and how to weigh them.  Complicating this, the data on which policymakers base decisions will, like this study, always be imperfect and incomplete.


At a deeper level, access to health insurance represents more than access to care, protection of financial assets and improved health outcomes; these may be the goals of health insurance, but its effects are broader.  A society that allows some, but not all, of its members access to health insurance takes a stance on fairness, or what a “just society” looks like.  Fairness as an ethical value is therefore the main ethical value at stake.


Many advocates of Medicaid expansion probably believe that fairness requires ensuring that all individuals have access to health care.  They probably believe this as a matter of respect or dignity for all persons, meaning that — independent of its health-related effects — ensuring equal access for all is required of a just society.  Rather than allow a justice-based claim to rise and fall with an ever-shifting and incomplete tide of empirical data, perhaps they should stabilize their cause with the ballast of fairness as a fundamental ethical value.


Is access to health insurance good for you?  The answer depends on what we count as “good” and which “goods” government policies promote.


decampMatthew DeCamp, MD, PhD, is a post-doctoral fellow in General Internal Medicine and the Greenwall Fellowship in Bioethics and Health Policy at the Berman Institute.  His current research interests include global health (including ethical issues in short-term global health training programs); medicine 2.0 and medical professionalism; and health and human rights with a focus on essential medicines.  He also sees patients in general internal medicine.

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