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26 EW NEWS & OPINION September 2013 Insights If something costs nothing, what's it worth? by J.C. Noreika, MD, MBA J.C. Noreika, MD, MBA "W hen someone with a political bias or vested interest sees a situation differently than we do, we tend to think that person is deliberately misinterpreting the obvious to justify their politics or to bring about some personal gain." In Subliminal: How Your Unconscious Mind Rules Your Behavior, Caltech theoretical physicist Leonard Mlodinow posits why our own opinions are always correct and others wrong. Our subconscious overvalues evidence supporting our beliefs and ignores that which conflicts. It is antithetical to our nature to maintain objectivity on important subjects. Think climate change, immigration reform, abortion, and, of course, the Affordable Care Act. Contention traced to difficulties establishing statewide Health Exchanges, postponement of the Employer Mandate, confusion regarding state-to-state Medicaid provision, and eye-popping increases in insurance costs borne by the young and healthy notwithstanding, the Affordable Care Act is the law of the land. But, as Mlodinow points out, tendentious minds will not be changed despite the fact that "our own reasoning is often not so perfectly objective." This essay describes the results reported in "The Oregon Experiment – Effects of Medicaid on Clinical Outcomes" published in the May 2 issue of The New England Journal of Medicine. The authors of the study represent Harvard's School of Public Health, Medical School and Kennedy School, the National Bureau of Economic Research, the Department of Economics at M.I.T., the Rand Corporation, Columbia University School of Social Work, and Oregon's Center for Outcomes Research and Education—an academic "Dream Team." The study differs from previous research correlating health insurance with health status. Its subjects were chosen through lottery drawings. In 2008, Oregon opened its Medicare Health Plan Standard to new enrollment. The 10,405 lottery winners were selected from a waiting list of some 90,000 individuals; 10,340 losers were the controls. The study engaged an "in-person data-collection protocol" that occurred an average 25 months after the process began. There were 12,229 respondents, a participation rate of 73%. Fifty-six percent were female, 72% between ages 19 and 49, and 69% Caucasian. All were poor. The researchers wanted to gauge how access to "comprehensive medical benefits including prescription drugs, with no patient cost-sharing and low monthly premiums ($0 to $20, based on income)" influenced health outcomes. Specifically, they analyzed the effect of insurance on the management of systemic hypertension, cholesterol levels, diabetes, and depression. They found a decrease in depression the only measure reaching statistical significance between groups. "Medicaid coverage did not have a significant effect on measures of blood pressure, cholesterol, or glycated hemoglobin." Even in higher risk groups of older patients previously diagnosed with diabetes or cardiovascular disease, there was no difference. The Medicaid coverage did increase the number of prescriptions written, doctors' office visits, and overall cost outlay. Visits to the emergency room and admissions to the hospital did not decrease. Coverage made no difference on the probability that a person smoked or was obese. The PHQ-8 index, an eightitem questionnaire, was used to screen for depression. "Medicaid coverage resulted in an absolute decrease in the rate of depression of 9.15 percentage points." The probability of a diagnosis of depression increased by 3.81%; there was no increase in the use of anti-depressants. Of the control group, 74.9% reported that they were "very happy or pretty happy" with their "healthrelated quality of life and happiness" compared to 76.0% of the Medicaid participants. If I understand, Medicaid coverage afforded access to doctors, hospitals, and prescriptions at little or no cost yet had no effect on improving outcomes for systemic hypertension, cholesterol levels, hyperglycemia, or the prevalence of smoking and obesity over a period of two years. Because the study utilized a lottery to determine eligibility, selection bias was controlled. Winners and losers were said to represent all uninsured eligible for Medicaid under the ACA in 2014. Many citizens, especially the young and healthy, will be asked to subsidize this entitlement. What, specifically, are they subsidizing? Access to doctors increased, more prescriptions were written, emergency room visits and hospital admissions did not subside. The authors found no improvement in objectively measurable outcomes. Only the subjectively determined diagnosis of depression showed statistical improvement. Is this a failure of the medical profession? The ineffectiveness of therapeutic drugs? Or the negligence of responsibility for one's own well-being? The U.S. will spend an unfathomable amount of money over the next several years to provide insurance for those without it. Politicians and academics rationalize that, in the long run, money will be saved by improving health outcomes of those at risk for expensive interventions caused by debilitating conditions such as diabetes and cardiovascular disease. Media commentary ran the gamut. Jonathan Cohn of NewRepublic.com wrote that "Medicaid virtually wiped out crippling medical expense among the poor." James Pethokoukis stated in BusinessInsider.com that "we now know what Medicaid is good for— almost nothing." Me? I think better outcomes start—and end—with the patient. Medicine is but the means. Of course, Leonard Mlodinow would say I'm biased. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com