One goal of the federal reform law was to increase the number of Americans with health insurance, which then presumably would increase their access to preventive care. Better access to health care services might also improve health-related behaviors like good diet, exercise, not smoking, etc.; or knowing that insurance is available may increase such behaviors, since it might lessen the consequence of engaging in them. A paper published by the National Bureau of Economic Research examines whether the reform law appears to have had an effect on preventive care and health behaviors. (NBER Paper) The authors looked at Medicaid populations and compared use of preventive care in states that undertook the Medicaid expansion versus those that did not. They also used data from the Behavioral Risk Factors Survey to see if Medicaid coverage appeared to affect those behaviors. The authors looked at a receipt of a wide set of preventive care services and at several “risky” health behaviors. In examining trends in use of preventive care and engagement in risky behaviors before the date of Medicaid expansions, the researchers generally found no significant difference between those states that accepted the expansion and those that did not.
Following the Medicaid expansion, the researchers, as you would expect, found that more childless adults had insurance coverage in the expansions states, compared to those that did not accept expansion. Also, fewer persons in the expansion states reported difficulty in receiving needed care due to cost. There was no difference, however, in people reporting whether they had a personal primary care physician. For most preventive care items, there was no difference in trends after the Medicaid expansion between the expansion and non-expansion states. The exception was a greater likelihood of a dental visit in expansion states and a non-significant increase in cancer screenings in those states. Similarly, there was little difference in the trends on risk behaviors, other than what the authors considered to be an implausibly large reduction in heavy drinking by females in the expansion states. Small, non-significant improvements in self-reported health status were recorded in the expansion states.
Overall, an honest assessment is that the Medicaid expansion portion of the reform law has done nothing to improve receipt of preventive services or to reduce risky health behaviors. This and other research supports the hypothesis that the connection between insurance status and health-related behaviors, including seeking preventive care, appears tenuous at best. In Medicaid populations that connection may be confounded by a variety of other factors which influence behavior. Less-educated, poorer populations tend to make worse decisions in most areas of their lives and getting them to engage in wiser behaviors is not easy. In particular in regard to this study, even though Medicaid may have been expanded in a state, not every newly-eligible adult took advantage of the expansion and enrolled in Medicaid. Undoubtedly those that did were more engaged in their health than those who did not. So time to stop the nonsense that we need to get everybody health insurance so that their health and health behaviors improve. Insurance status has little to nothing to do with people’s health.