The theory is that expanding people’s access to health insurance also expands their access to health care, and they will ultimately be in better health. The flaw, of course, is that we are talking about human beings. There are several lines of research trying to ascertain the effects of health insurance on health behaviors, which obviously have a large effect on health status. Insurance can promote better health, if people use it to get needed services, but it can also promote poor health behaviors by removing consequences. A paper from the National Bureau of Economic Research attempts to ascertain whether the expansion of insurance coverage under the ACA had an impact on health behaviors, a difficult task. (NBER Paper) The researchers used data from the Behavioral Risk Factor Surveillance System, which annually asks a number of questions regarding health behaviors and other outcomes from about 300,000 non-elderly adults. They compared behaviors from states that implemented the Medicaid expansion and those that did not and they examined changes in states which had varying rates of pre-ACA uninsured persons, thereby including the effects of the individual mandate and subsidized exchange coverage. The good behaviors were getting a physical exam, a flu shot, a pap test, an HIV test or a mammogram. The bad behaviors included drinking, smoking, high BMI and lack of exercise.
Prior research has suggested that gaining insurance coverage may encourage some greater preventive health service use, but also may worsen certain health behaviors, like smoking and drinking. This study uses a slightly longer follow-up period, three years, but generally comes to similar conclusions. The researchers adjusted the results for a number of demographic and socioeconomic factors. Generally, before the ACA expansions became effective, preventive care rates were higher in states that ended up adopting the Medicaid expansion and poor behaviors were more prevalent in non-expansion states and those that higher rates of the uninsured. Trends were similar across various combinations of insured rate and expansion status. The Medicaid expansion appears to have had no statistically significant effect on preventive care rates. The individual insurance mandate and subsidized coverage appear to have generated very modest increases in use of preventive care. The expansion may be linked to an increase in risky drinking and to statistically insignificant increases in other poor health behaviors. There was some suggestion that poor health behaviors increased in the third year after implementation. Low-income people seemed to have the greatest improvement in preventive care use. Higher-income individuals showed the largest increase in risky health behaviors.
What really emerges is that people with a syndrome of poor behaviors–health and otherwise–are least likely to benefit from insurance coverage expansion. These people are the ones more likely to be Medicaid-eligible. Those who are generally more responsible–have jobs, etc.–take advantage of their new insurance coverage to get preventive care, but also may use freed-up income to smoke and drink and eat more. Those are gross generalizations, but I think they really point to is the need to address very early the at-risk populations that are likely to make a hash out of their lives and find ways to intervene and help them get a good education, a good job and find meaning in life. That will be the best thing to improve their health.