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The Oregon Medicaid Lottery

By May 6, 2013Commentary

Occasionally in health care we have the opportunity to observe a real life experiment which may inform our understanding on key issues.  For decades we have been told that a lack of health insurance was linked to poorer access to health care services and therefore worse health outcomes, including greater rates of mortality.  In Oregon, the state a few years ago recognized it had limited funding to provide coverage to uninsured low income residents so a lottery was instituted to provide coverage for about 30,000 out of 90,000 people.  Research reported in the New England Journal of Medicine compares health outcomes for the group getting insurance with those still on the waiting list.   (NEJM Article)   Their were about 12,200 people in the final study and the authors carefully adjusted for differences between those with and without coverage.  A wide range of outcomes were examined.  Getting health care coverage, with its presumed better access to services, had no significant effect on blood pressure, lipid levels or diabetes measures.  It also did not lower the ten-year likelihood of a cardiovascular event.  Coverage did not increase rates of diagnosis and medication use for blood-pressure or high lipids, but did do so for diabetes.  There was also an increase in rates of depression diagnosis.  There was slight improvement in the covered persons’ perceptions of their mental health status, but not their actual physical health and they felt less stress in regard to financial hardship related to health care costs.  As might be expected utilization and spending rose significantly for the covered group.

So lets be blunt about the real message of this study:  Oregon spent a lot more to get very little improvement in health status or outcomes.  The usual suspects are spinning madly to try to minimize the damage from the study, which undermines a key supposed reason for radical reforms.  Here is what really should be recognized:  people’s health has a lot more to do with how responsibly or irresponsibly they live their lives, and giving them free medical care neither improves their health nor, more importantly, makes them more responsible.  Giving people health care doesn’t stop them from smoking, drinking, using illegal drugs, eating very poor diets or help them get more exercise, have meaningful relationships that reduce stress or get a job.  Until we put the focus, and the financial incentives, back on personal responsibility, don’t expect unlimited free health care to do anything significant to improve health.  And meanwhile we are adding financial stress to the responsible portion of the public that has to pay the taxes for all this free care.


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