How the Oregon Medicaid experiment is a failure

How the Oregon Medicaid experiment is a failure

An important article was recently published in the New England Journal of Medicine, titled The Oregon Experiment — Effects  of Medicaid on Clinical Outcomes. This study provides a rare look at the effects of expanding Medicaid coverage (specifically, Oregon Health Plan, Oregon’s version of Medicaid) to a population of previously uninsured patients. Having practiced medicine in Portland, Oregon during the time of this study, I was excited to read the results.

The basic premise was that a group of 12,229 uninsured people were selected as study participants, approximately half of which were newly enrolled in Medicaid, while the other half remained uninsured. The participants were then tracked over two years to determine the overall effect on mental and physical health.

To summarize the results, the Medicaid population spent more Medicaid dollars ($1,171 on average) to access more health care, most notably office visits, prescription drugs and mammography screening. In doing so, they felt less depressed (when asked on screening exams), but did not have better outcomes on any physical health metric, including diabetes, high blood pressure and high cholesterol management. They did however experience less financial hardship, including a decreased likelihood of incurring a catastrophic expenditure (defined as an out of pocket medical expense >30% of annual income).

There are two general schools of thought that have emerged since the results were published.

One is, “Health insurance does not necessarily make people healthier,” highlighting that there was no improvement in any objective measures of disease management.

The second is, “Health insurance works.” Citing the 4% decrease in catastrophic expenditures found in the Medicaid population, this group states that health insurance is doing what it is supposed to – shielding people from large financial losses in the case of a rare event.

Personally, I tend to agree more with the former than the latter, for a very simple reason: return on investment. As we get ready to spend billions of dollars to expand health insurance coverage to millions of people, we need to see improvements in health outcomes in return. While financial security is a worthy goal, it comes at too high a price if it is the only benefit. After all, the subtitle of the study is ‘Effects of Medicaid on Clinical Outcomes’, of which there were none demonstrated.

The treatment of chronic disease drives health care expenditures. Last year, we spent $245 billion on diabetes alone, a 41% increase from just five years prior. That is a staggering number, and it will only grow as the long-term effects of poorly managed health manifest in our patients.Without improving the treatment of these diseases, we will never reign in health care costs, or make anyone healthier. Based on limited evidence, it does not appear that Medicaid expansion is the silver bullet.

Unfortunately, the conclusion that expanding health insurance coverage does not improve physical health is not that surprising. We currently operate within a broken health care system. Inefficiencies and redundancies abound, while third parties add layers of complexity that only increase the price of goods and services delivered. If patients, physicians and politicians accept this fact, then clearly the solutions have to be tailored towards fixing the system, not simply granting greater access to it. It is the difference between health care reform and health insurance reform, and it is a distinction that many have failed to make.

It is important to understand that the Affordable Care Act (ACA) is, first and foremost, a reform of the health insurance market. While the legislation contains other elements of reform, these changes are dwarfed by those in the insurance marketplace. For example, consider that Medicaid expansion is projected to cost an additional $952 billion over the next decade, while the 10-year operating budget for the CMS Innovation Center, which is tasked with transforming the way we deliver care, is a (relatively) minor $10 billion. Likewise, Medicare payment reform is projected to save taxpayers $200 billion over five years, while the much-publicized medical device tax is projected to generate just $10-30 billion over ten years.

Clearly, the goal of health care access has been vigorously pursued at the expense of focusing on health care quality and cost. The debate will continue as to whether this approach will pay dividends as we begin to roll out many of the major ACA provisions in 2014. Given the protracted timeline for complete implementation of the health care law, it might be ten years before we have a definitive answer. My concern is that the data from The Oregon Experiment is the earliest indication that we are going to be dealing with many of the same problems in 2023 that we have in 2013.

Thomas Santo is a physician who blogs at Scope of Medicine.

Image credit: Kelly Santo

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  • PamelaWibleMD

    Health care should never be a passive experience. Free services do nothing to motivate a population to take an active role in their own health. So unlikely to see lasting outcomes. Give a man an apple and you feed him for a day. Teach a man to garden and you feed him for a lifetime.

    I’m a doctor practicing in Oregon and I chose not to accept OHP as an insurance. I see patients regardless of their ability to pay in a cliic designed by the patients themselves (www.idealmedicacare.org). This creates an ACTIVATED patient panel. I ask those who are low in funds to contribute back to the community (volunteer in soup kitchen, help other patients, plant a garden, etc. . .). Patients who receive free services tend to undervalue them and become passive in their approach to care. Getting them up and active in the care of themselves and the community inspires them.

    “Health care can never be mandated. Most people suffer ill health from poor lifestyle choices. Legislation can support healthy behavior, but laws can’t force people to care about themselves–or anyone else. Compassion comes from the heart, not the pen. Caring is a personal choice . . ” excerpt http://www.petgoatsandpapsmears.com/why-pet-goats.php

    • PamelaWibleMD

      oops mistyped the first link: http://www.idealmedicalcare.org
      Yes, we need to put patients in charge of designing their own clinics and hospitals. They will feel like a valued part of the health care system rather than passive recipients.

      • Patricia

        Again, I like what you are saying. But the way you keep saying it is paternalistic. Why in the world do you think people are ‘passive recipients’? That’s pretty absurd. People are people, some are active and interested, some are overwhelmed and just can’t cope very well, and yeah some might be what you would call “passive” but are they really? Showing up to a doctor for care is not passive. It’s pretty much what people are taught to do.

        • PamelaWibleMD

          Happy to speak with you further. This conversation is far more involved that what I feel I can write in a few short comments. Contact me: http://www.idealmedicalcare.org

    • Elvish

      Doctor,

      1. Where did your residency program get your training $$$ from ?
      2. Do you think it`s ethical to deny a patient because they were carrying the “wrong” type of insurance ?

      • PamelaWibleMD

        I do not deny any patient care due to insurance. I see anyone who wants to see me.

        • Elvish

          “”I’m a doctor practicing in Oregon and I chose not to accept OHP as an insurance.””
          This statement got confused.

          • azmd

            I think we should all be clear that in the U.S., doctors pay for the majority of their training all by themselves. Medical school costs, which are very significant, are paid for entirely by the student, generally by taking on educational debt which can take a lifetime to pay off.

            At the point where a doctor is a resident, they are providing an extremely valuable service to the hospital, for which they are grossly underpaid. By contrast, lawyers and bankers are paid reasonable salaries right after they complete their training, while receiving essentially the much same type of on-the-job training as residents do.

            To imply that, because the taxpayer subsidizes the hospital’s cheap labor costs, the individual doctor (rather than the hospital) owes a debt of public service over the rest of his or her professional lifetime, is a dangerous position to take in our present system. Medicine is becoming an increasingly unrewarding profession especially for primary care. Many parents like myself are encouraging their bright, hard-working and well-educated children to look elsewhere for careers where the educational debt load will be more manageable and where they can expect to have a reasonable amount of professional autonomy over the course of their working lives.

            At the point where our society tells doctors that they are not able to determine for themselves whether or not they wish to be involved with third-party payers, governmental or not, we are making a dangerous intrusion into one of the core concepts of professionalism, which is the ability to have some sort of control over one’s working conditions.

          • Elvish

            Hmmm, I think we are in debt to our society, at least those of us who practise medicine because they love medicine and love to help others, think so.
            Are medical students and doctors in training in debt for their patients because they let them practise on them ? I think so. You can`t be a doctor practising on standarised patients.
            We do the thing that we love to do, help patients and make money ! It is the best the job in the world !
            I too hate to have a 3rd party between us and our patients.

          • Disqus_37216b4O

            “I too hate to have a 3rd party between us and our patients.”

            Is someone forcing you to do this?

            If you hate it, just stop. Just stop taking insurance. Deal directly with your patients if you want, it’s still a free country.

          • Elvish

            How do you suggest I do this ?

          • Disqus_37216b4O

            Dr. Wible looks like she’s got some good ideas and has actually put them into practice, try asking her for advice. Ask around at any of the increasing number of direct pay practices which are popping up.

            Lots of doctors are just as sick of having a 3rd party payor coming between them and their patient as you are, but instead of just whinging about it on blogs they’ve actually taken action to make a change.

            “Be The Change You Want To See.”

          • Patricia

            Not really that much of a free country. Well I mean for some people it’s not.

          • Patricia

            What government should do is provide free education. Period. Then those that can, will do. You are right, the doctor should not be caught in the middle of all this; yet the doctor needs to participate in a way that improves not only their own outcome but those of the people they serve (the patients/clients). Saying no to ACA is not the right way to go in my opinion.

            Also many people who have gotten law degrees are not finding work. I think doctors have better luck. And don’t doctors in training get fellowships and such? Try being Public Health, there is practically no funding available for that and most programs are fee-based (no scholarships, no nothing).

          • Guest

            Who is going to pay for all of this “free education” and “free healthcare” you want to legislate? You’re aware that “the government” doesn’t actually have any money of its own, it only has what it takes off productive citizens.

          • Patricia

            Well I am really tempted to unload a bunch or rhetoric as you have done but I’m trying to think it is better to educate than to fight. However, wow, these topics are really huge. My suggestion to you is to investigate and explore with an open mind issues like social equity, and health care for all, the effects of racism and poverty. And while you are at it….check out how free market capitalism has destroyed our society and economy. It really goes beyond the rhetoric.

            By the way, what exactly is a ‘productive citizen’? Is that someone who is weighted down with healthcare or student loan debt? I don’t think so.

          • Guest

            “free market capitalism has destroyed our society and economy”

            ::facepalm::

          • Patricia

            Your response is disappointing. However, there are many many economists and leaders and academics in this country who can see how this true. One only needs to look at the recent financial crises (including the housing market bubble) to see how this is true. You can also look into the influence of Big Pharma (and any other “Big” powered profit-driven entity) Health care delivery is no different.

            The problem with all these conversations that on these topics around health care, insurance, etc is that people don’t really *know* or consider the facts. They don’t look at other countries who offer universal health care (and the subsequent health of their citizens) or regulated capital markets. If you want there to be more and more sick people, more of a gap between the rich and the rest, and social inequity…then I guess supporting what we do as a country now will ensure that is what we get. Not claiming to be an expert but I can at least do a bit of research and learn. So “facepalm” away. I think that just shows you are close minded on this subject.

          • PamelaWibleMD

            Yes. I know it can be confusing. I accept all patients. I do not accept all insurance.

    • ThomasSanto

      Thanks for your comments Pamela. I agree, an active, engaged patient is essential for good long-term outcomes. Best of luck with your care-delivery model in Oregon.

    • ninguem

      So what happens when your day’s schedule is filled with people who won’t pay, and are all planting marijuana gardens?

      • Patricia

        Even though your comment is snarky and mean, it’s still a good question, in that: yes, what if no one can afford to pay and the doctor is left with a clinic full of non-payers.

        • ninguem

          Pam knows I’m on her side. I get snarky when I eat too many Circus Peanuts. And I try not to get too mean, she’s been seen around town with a 50-cal Bushmaster.

          • Patricia

            :)

    • Patricia

      I like your idea of activation patients in their own health care and health. However, your attitude is a bit paternalistic. I guess you get a pass because you are offering this service to people who can’t pay and I think that is wonderful. But what I don’t see any docs (or hardly any) addressing is what truly contributes to good health(?). It is NOT lifestyle choices. It is what comes before that (hmm..cheap crappy food in poor urban environments, the stress of poverty, the stress of discrimination, etc etc.).

      Check out the movie Unnatural Causes, if you have not already.

      • PamelaWibleMD

        Prevention is part of the ideal community clinic model. I teach my patients to garden. They get free seeds at their appointments. Prizes for quitting smoking. More about the clinic ins the book: http://www.petgoatsandpapsmears.com

        Will look into the movie. Thanks Patricia!

        • ninguem

          Pam, a while ago, I sent the Portland Oregonian a letter, ripped them a new one.

          They had run an article about one of your local big box entities dropping out of the Oregon Health Plan.

          The headline ran, “Big Box Healthcare Organization Drops Participation inOregon Health Plan”. The article went on to quote a Big Box executive noting that OHP payments were less than the cost of doing business. You know as well as anyone, if you ran on OHP, you could work for free, you wouldn’t be able to pay the electric bill and the rent on OHP payments.

          Bearing in mind, too, that Big Box gets facility fee payments, they can get nearly double what you or I get for the same work.

          Well……fine.

          Six months or so later, the article came to mind, as I saw still another article on individual physician practices in Oregon that dropped
          OHP participation.

          The Oregonian headline ran:

          “Many Doctors Reject The Poor”

          I sent the editorial board the two clippings from their archive. Explain the editorial policy by anything other than anti-physician bias?

          What good it did, I don’t know. I got a letter of apology from the editor, with bloviating about how hard it is to craft the appropriate headline, and lots of tap-dancing about how the blatant bias was not actually bias.

          I felt good for a day or two.

        • Patricia

          I think you will really like this documentary. (One does have to pay for viewing it). Another one is in the works. And I believe some people from UW are working on it.

    • querywoman

      Community work, volunteering in the soup kitchen, etc., is a modern version of paying in produce for care and is appropriate.

  • Disqus_37216b4O

    “It is the difference between health care reform and health insurance reform, and it is a distinction that many have failed to make.”

    Can’t be pointed out often enough.

    Excellent post.

  • Dave

    While I disagree with the conclusions you’ve reached (for many of the well-publicized counter arguments and interpretations that don’t need repeating), I appreciate your distinguishing between health care and health insurance. ACA supporters (myself included) have a tendency to lump the two together to argue in favor of our position, but in fact they are very different. If you go back and read articles from the mid 20th century, they originally called it “doctor bill insurance” or “hospital bill insurance.” Terminology like this seems to do a better job of separating the two; the word ‘health’ in the name brings baggage with it.

    On the flip side, ACA opponents will often make this distinction to argue against insurance reform while offering no real solutions to improve health care either. It’s far easier to argue against something than it is to create something new and better in its place.

    • ThomasSanto

      Dave, thanks for your comment, I hear you regarding the ‘criticism without solutions’ situation – it happens too often. Although, to be fair, I have seen solutions offered that are dismissed if they don’t fit with the overall agenda of the ACA. Going along with my post, I think there are real solutions, some of them are within the ACA, but are under-emphasized to the point that they will never have the necessary impact – the CMS Innovation Center and patient centered medical
      homes come to mind. I also think increased patient education is an enormous (necessary?)
      tool to improve care that has not been adequately addressed under the law.

      • Patricia

        And this is because the law had to be reformed over and over because of partisan opposition. And those types don’t care about the health of the population. As an aside, a state senator was sitting on a hearing that was addressing the fracking industry. Citizens were complaining that their water was polluted and making them sick. The senator disregarded the flaming dirty water and instead said that he only cared about the jobs the fracking would bring to the state. (And I wonder what dubious supporters he had in that state?).

        • J. Miller

          “the law had to be reformed over and over because of partisan opposition.”

          The Democrats had a supermajority in Congress, and a Democrat president. They could have passed anything they wanted.

          • Filo Bedo

            Oh those pesky facts…

  • azmd

    Just out of curiosity, has any research established a meaningful correlation between metrics such as glycosylated hemoglobin and good health? I know that we like to track measurements such as blood pressure because they are simple data points to tabulate and analyze, but what do they mean?

    I find it interesting that the study participants were less depressed and rated their own health as improved, but the study has concluded that they actually did not benefit from improved access to care, except financially.

    Additionally, it seems a little disingenous to claim that the financial benefit fell to the individual patients. The fact is that catastrophic medical debt goes largely uncollected and is absorbed by our hospitals. To the extent that the medical debt is covered by a third party payer, it is the hospitals that benefit, which does not seem all that unreasonable to me.

    • ThomasSanto

      azmd, thanks for your comment. To answer your question, there is a substantial body of evidence that a high HgA1c level (i.e – ‘diabetes’) is a significant risk factor for other poor health outcomes, such as coronary artery disease, heart attack and stroke. Peri-operative outcomes have also been shown to be worse in diabetics, especially those with poorly controlled disease (high HgA1c).

      • azmd

        Thanks, for that helpful response. Has any work been done on what period of optimal care is typically required in order to bring dietary habits and glucose control into a range where HgA1c levels normalize?

        • Patricia

          Totally agree! And if these services were provided (as well as changing the elements of low SES, etc) We would most likely see a great benefit to the health of the American population. But certainly it would take more than two years.

  • Peter Elias

    Since the studies were significantly underpowered to show whether health outcomes (specifically A1c, BP, Framingham risk score) would be impacted one cannot use the study as evidence that outcomes are not improved by insurance. Not showing is not the same as showing not.

    • ThomasSanto

      Peter, thanks for your response, the issue of power is a real one – the authors of the article devote almost half of their discussion to it. They do however explain that sub-group analysis and Framingham risk score were an attempt to increase the power to detect a difference, but still did not see one. For me, the key quote from the authors’ regarding ability to detect a difference is, “Beyond issues of power, the effects of Medicaid coverage may be limited by the multiple sources of slippage in the connection between insurance coverage and observable improvements in our health metrics; these potential sources of slippage include access to care, diagnosis of underlying conditions, prescription of appropriate medications, compliance with recommendations, and effectiveness of treatment in improving health”. So was it the lack of power, or was it really the factors cited above that led to the inability to show a difference? Debating methodology is more than reasonable, but to categorically dismiss the study results, or the implications of those results, as some have tried to do, is not fair in my opinion.

      • Peter Elias

        I most certainly did not mean to dismiss the study results, categorically or otherwise. I think it is a useful study. I am bothered by the tendency by some to use this study to say that insurance doesn’t improve outcomes – because I don’t think the study says that. While I suspect that the sources of slippage you describe are a bigger factor than study power, only further studies would validate or refute my speculation.

    • Disqus_37216b4O

      “Not showing is not the same as showing not.”

      If there were no evidence that a new $100,000 drug had any impact on breast cancer, would you still reach into your own pocket and buy every single breast cancer sufferer in America a lifetime supply?

      I mean, there’s no evidence that it DOES help, but then again “Not showing is not the same as showing not”, right?

      If it were your OWN money you were spending, would you do it?

      • Peter Elias

        That’s a valid point, which I see as the flip side of the point I was trying to make: this study is not powered to either support or argue against the value of insurance for the variables studied. This leaves us with the vexing problem of answering questions like yours without data.

        • Patricia

          I think you are exactly right. And the problem is that when people are claiming to go by “evidence” they are actually suffering from confirmation bias. They are against the agenda to begin with.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        All we can say about the Oregon experiment is that the $100,000 drug which has been proven to work very well for other populations, seems to have little to no effect when extensively diluted with righteous rhetoric to make the treatment cheaper.

        The solution is not to withhold the drug, but to administer the correct dose and strength. Perhaps Oregon should try another experimental round of Russian Roulette or whatever they’re playing up there…

  • Elvish

    To those who are claiming to be “physicians” and “carers” for the less fortunate ones, what I was taught in medical school, to them I say; Do not blame the sick for being sick and do know that we all are going to be sick someday.

    • Disqus_37216b4O

      You say “do not blame the sick for being sick”, and that’s fair in a general sense. But somehow people must be motivated to take basic care of themselves. Physicians can only fix them once they’re broken.

      I require my children to brush and floss their teeth thoroughly each night before bed. This is part of a “basic maintenance regimen”. The dentist can only repair any damage done, maintaining basic oral hygiene is up to them.

      And yes, if next time they go for a checkup the dentist tells me that little Johnny has three cavities and has either not been brushing & flossing well or has been sneaking candy after bedtime, I will be disappointed, I will “blame” little Johnny for the subsequent three fillings he’ll require more than I would for, say, the capping of a tooth broken in falling off his bicycle.

      “Personal responsibility” seems to have become a dirty word lately, shouted down with cries of “Oh, don’t be JUDGMENTAL!” I don’t think this is a good trend.

      • Elvish

        Right, my problem is with our way in delivering this message. I feel it`s so negative. We can do better.

        A friend of mine was telling the other day, that an elementary school near by is teaching their youngsters how to grow vegetables, how to cook healthy food and how to live healthy.
        I think it is a brilliant idea and will have amazing outcomes down the road.
        We can do the same thing with older patients.

        • Patricia

          There are a lot of great programs that can be implemented to help improve health; however many of these programs are subject to funding cuts and not supported by anything stable. Really what we need is an over-arching mandate that will reach many through community work. Do do this, people have to stop separating out the classes and judging those at the bottom. And seeing them as ‘less than’. Or as if they are not working hard and just taking handouts.

      • Patricia

        You know, the reason “personal responsibility” seems to have become a ‘dirty word’ (phrase) lately…is because personal responsibility is not at the root of the health issues Americans face. Some of the causes of poor health are poverty, pollution, discrimination, the enormous income gap. And if you don’t agree with this then you can very easily find enlightened doctors who understand these concepts and read up on it.

        So my response wouldn’t be : Oh, don’t be judgmental! It would be: Oh, please educate yourself, and don’t be so ‘knee jerk’.

        • J. Miller

          Poor people are just people without much money, they’re not retarded or lesser-evolved creatures who are intrinsically incapable of learning basic living and self-maintenance skills. Perhaps it is the very low expectations you and your ilk have for this subclass of child-like untermenschen (as you see them) which is causing as much damage as anything. “Self-fulfilling prophecies.”

          • Patricia

            Are you joking? This is the most ridiculous statement. I find it really amazing the amount of anti-poor comments on this thread (and others).

            First of all, I am of no “ilk” as you say. I have no expectations of people per se. That’s not my place. I am lucky to be an educated person. Yet I am also a member of the “working poor” class. I understand the barriers people face. Your comment is paternalistic and seems to say that a certain class should not reduce the expectations another “class” has of itself.

            These are individual people who are in groups of people. Who face barriers that other groups of people (um…rich, and white, and male) don’t face. And please don’t at all take my word for it because it’s obvious you just want to make your opinions known; instead do some research. That’s all you have to do. Watch Unnatural Causes. Read about population health (and health by zipcode). It’s all out there.

  • ninguem

    Anybody who has practiced in Oregon knows the Oregon Health Plan is a failure.

  • disqus_qJEMXTKtR1

    Thanks for calling our attention to this NEJM article. The Affordable Care Act is not perfect, so studies such as this might allow us to “tweak” it toward improvement.

    Thomas, could you specifically reiterate anything that you see from this study that might provide solutions improving this law so it doesn’t fail?

    Gene Uzawa Dorio, M.D.

  • Anthony D

    As an American citizen, I have to support my U.S. government.

    However the overall results have been disappointing with the IRS, NSA, and EPA.

    So it doesn’t take a genius to recognize incompetence!

  • Patricia

    This is disturbing in the sense that you are placing a financial value on people’s lives. People aren’t worth the healthcare expenditure? Well, look, you can call the program a failure but I would find it very hard to agree with you. Following a group of people for two years who had not previously been insured does not seem to be enough time to help chronic health problems. Especially since these problems are pervasive and caused by things that health care doesn’t address.

    Not only this, it seems a bit of an entitled opinion. I am sure that *you* have health insurance (being an M.D. and all). Not only that you have a high level of education (which is associated with good income and good health). So it’s easy for you to distance yourself from this very real and very human problem. Why should poorer people not have health care? To me that is the most absurd thing about this country. It’s unfair and unjust. Imagine having insulin dependent diabetes and not being able to afford insulin… How can that be right?

    The reason the ACA needs to be ‘tweaked’ as someone mentioned is because it could not be put forth in the manner it was first intended because of partisan politics. And those politics don’t protect the poor. Not only that, any new system will take time to implement and make work. What we have has been allowed to run unhindered (benefiting big pharma and big insurance) for so long, how do you expect to turn it around in a mere two years?

    No, health insurance does not equal better health. However if we can’t or won’t change the things that WOULD improve health than people ought to be able to go to the doctor without having to spend most of their income on doing so.

    • ninguem

      Patricia – “…..This is disturbing in the sense that you are placing a financial value on people’s lives. People aren’t worth the healthcare expenditure? Well, look, you can call the program a
      failure but I would find it very hard to agree with you…….

      Placing a financial value on people’s lives is the very essence of the Oregon Health Plan.

      The Oregon Health Plan’s prioritized list, and “the line” is, by its very nature, placing a financial value on people’s lives.

    • J. Miller

      So even though taking money out of working families’ pay checks and handing it to those who don’t work so that they can have all the “free” medical care they can eat, doesn’t have any positive impact on their health, we should keep doing it, because… why, again?

      Why don’t we increase EVEN MORE the tax on the 50% of people who actually pay tax, and take that money and just cut a check for $5000 for everyone who _doesn’t_ pay tax? That would have the same impact on their health, and cut out the middleman entirely.

      • Tom Garvey, MD

        How to spend money is a matter of opinion. Where it comes from is not, and Romney’s famous 49% line is wrong. While only ~50% of people pay federal income tax, everyone pays sales tax, excise tax, etc. Most pay Social Security tax (which falls disproportionately on low and middle income). Also, many of those who do not currently pay income tax have done so (the elderly) and will do so in the future (the unemployed). Of the 18.1% who pay no income or social security tax, over half are elderly, and over a third are working poor making less than $20k/yr.

        Divided into groups of 20%, the total taxation paid by each income group ranges from 7.9% to 11.3%. The 11.3% is paid by the upper middle income group and the 7.9% by the lowest.

        However, those in the top 1% pay 1.5-7.5% of their income in taxes depending on the state. They take home 24% of all income in the country. The bottom 20% take home 3.5% of all income.

        How those taxes are spent are a different question. I happen to think that government money spent on effective healthcare is worthwhile. But taxes are paid in a roughly equal proportions by all sectors of society except the top 1%.

        • querywoman

          Under the current system, will all these taxes, the uninsured upper middle class pays more for health care than anyone. They pay all these levels of taxes. They pay out of their pockets, almost always at higher rates than the contracted insurance rates.
          I know, I had a relative who had a stroke and chose to stay at the hospital half a night! She got no physical therapy.
          She was apolitical and didn’t vote.

        • Patricia

          Well said! And don’t forget the corporations that don’t pay taxes. I wonder how many people posting here have mac computers and realize how Apple doesn’t pay that much and ships all it’s work overseas. But no, gotta have our macs.

    • Filo Bedo

      My wife is an assistant director at a private school. The former owner was a wealthy woman who built the school from scratch. We would help her from time to time with things. Graduation or Christmas programs were great. The decorations, awards, etc., were great and the parents were always pleased with not only the programs, but the product which they paid for, which is a student that was well educated, and well prepared for their next level of education. What people always saw was the product, a nice facility, exceptional students, a great program (graduation, Christmas, talent show). What they didn’t see was the countless hours that was put into this effort. Setting up until 2 or 3 AM, drive home, then back again at 8 for the program; 12, 13, 14 hour days every day; working weekends; little to no personal life; managing; 20-30 nagging (not all of them) employees. No, people saw the product. Not the sacrifice. They simply showed up and watched the program.

      Likewise, you say “being an MD and all” as if were bequeathed like some gift and not earned. You didn’t witness the countless hours of studying so a competitive GPA was maintained; the nights of only 3 hours of sleep or less; all of the missed family events and dealing with the friends, family, or spouse that didn’t quite get it; the stress; the MCAT; the USMLE or COMLEX; finding the time for a descent BM; and the 12, 14, or more years it took to achieve their goal. You’re damned correct docs should have great insurance. They earned it.

      It is pretty clear by your statement that it is not those that own their lives and earn their way who have a entitlement issue.

      • Patricia

        Wow. You have quite a chip on your shoulder and elevated view of yourself. I know plenty of people who have worked very hard, at manual labor jobs, all their lives. They may not face academic competition, or tests. Would you rather face low wage, physical work that depletes your soul and body? And do this for your entire life? With no real opportunities to change this situation? Don’t talk to me about choice either, because education is out of reach for many many people. And good education (as in pre-college) is as well.

        It’s odd that your story begins with talking about a private school. Private school is privilege. So is higher education. Please do not talk to me about “earning”. Get off the high horse and realize that people who work hard scrubbing toilets and mining coal, serving food…all those kinds of jobs deserve to be healthy, get health care, and be respected. They do not deserve to be vilified as folks who have not earned their way or paid their dues in this world. I know people who have died from treatable diseases because of crummy healthcare (disinterested and judgmental healthcare providers).

        Oh and I also know wealthy doctors who have gone through all you mention (even the spouse who just didn’t ‘get it’ .boo hoo.) and you know what…they got great lives. Money, health care, respect. I am willing to be you they would not trade a day working manual labor jobs that people spend their entire lives into old age, doing.

        • Filo Bedo

          Hmmm…

          Patricia, I think you might be assuming too much and missing the point.

          -”You have quite a chip on your shoulder and elevated view of yourself.”-
          How so? Did I miss where I bragged about myself? My point was docs earn their way. I’m not a doc. I begin med school in the fall; thus, I have nothing to brag about here on this blog site. I’m not a pimple on the rear of a physician. Chip? I’m not the one speaking – about those who have more than I do – with contempt.

          - The poor, opportunities, vilification-
          Do you think I am some privileged brat? You speak of the poor as a few people that you know. I come from the poor… I lived it. I’ll spare readers the details, but I will say I was raised by a single mom who waited for us to finish our food before she ate, church brought us food at times, welfare, etc.; and I have done the jobs you mentioned (except coal mining) among others: shovel, jackhammer, etc. I used every opportunity available to me to get through school and there are opportunities. To say otherwise is a boldfaced lie.

          -Private school-
          I didn’t attend private school, my wife didn’t attend private school. I attempted to illustrate how people don’t understand or respect the work that goes into creating success. They often only see the product.

          - Wealthy doctors who wouldn’t trade it-
          Why would they? Are you saying that the poor that you “know” would go backward if they became docs or are you just aimlessly ranting? I’m not sure what your point is here (beyond airing out your contempt) or how this argument ties into mine?

          This has been my experience and I certainly hope it resonates with you but I have no expectations. You can take it or leave it.

          • Patricia

            Your thoughts are quite hard to understand then if you came from a poor background. Because then you would know that poor people work and earn and sometimes the success they experience is just being able to pay the rent and the car insurance. Yes, doctors earn what they have in life. I have no contempt for people just living their lives and doing what they can. I do have contempt for those who want to “blame the victim(s)” rather than those who are truly to blame. Doctors have enjoyed a lofty place in our society but that’s changing and I sense they resent it and blame the poor for wanting “something for nothing”. Which really, that’s hardly true. AND the people who actually get something for nothing easily deflect their deeds into poor-bashing propaganda.

            I understand your point but I don’t think you presented it very well in the first place.

          • Filo Bedo

            I have to consider that I may be a bit confusing when trying to present my thoughts. Likewise, you may want to consider that your confusion may be based on compartmentalizing your pre-concepts.

            Poor does not automatically equal humility, the absence of greed, or any other characteristic. I know plenty of people who work their tails off and I also know plenty that depend on excuses to remain exactly in the position that they are in. Some are decent and some are absolute parasites.

          • Patricia

            True, true. But we must look at society as a whole when we think about creating change, right? Individuals are not good examples of anything. I don’t think “poor = noble” . I just think that people who are poor have so many barriers to healing and improving their lives. (The way the tobacco industry targets certain groups is a good example of something poor folks have to deal with, without really knowing it). I think attitudes towards “the poor” is so ingrained in society (in general) that people have automatic thoughts about the situation.

          • Filo Bedo

            As a society, I think it is important to thoroughly approach a problem from a reductionist to a holistic standpoint. It is important to analyze how the actions and patterns of behavior of individuals that collectively make up a system can determine the environment (health, culture, etc.) of a system. Conversely, it is also important to acknowledge how the environment (the collective output of the individual) can affect the individual. Neither should be overlooked or underestimated.

            However, for the individual, the only way to improve our situation is to take ownership of our own lives. We all have hurdles and shortcomings. We all have resistance of some sort. I personally won’t waste my time worrying about those who have some sort of leg up or advantage over me.

            In high school, I had to read a paragraph 5 or 6 times to get the gist. I would walk into class and my classmates would be turning in homework I never knew was assigned. I was always lost and behind. I even dropped out for a period because I was so discouraged. College was not a topic of discussion growing up and no expectations were placed upon me or my siblings. I graduated from a well respected university with honors and will be starting my first year of med school this August. The difference was that my outlook and understanding of life changed, which led to a change in attitude, which then led to a change in direction. But not only has my life changed, my children’s lives have as well. We regularly talk about college as a matter of fact, not just a matter of hope.

            We are a Mexican-American family that had a background with some of the stereotypical “minority” characteristics. I am well aware of the socio-economic statistic. But my wife and I, as individuals and as partners, reject that type of mentality. We push forward and mold our own future as well as the future of our children. That has worked for us so far.

            Hopefully that helps you understand where I am coming from a bit better.

          • Patricia

            I do understand where you are coming from; and I appreciate your perspective. And it’s true, some people are able to mold their future and overcome adversity. But there are structural problems within our society that affect a person’s health. And these are not easily overcome, if at all. If we think about the experience of Blacks in American and Native People, we can see how historical and present racist structures prevent them from achieving good health and pushing forward in life.

            I think in many ways, Hispanic Americans have certain cultural qualities that actually help them to overcome some structural problems that exist. But in general many people do not. Let’s think of the White poor in Appalachia. Or now poor women who need women’s choice (abortion services) in places like Texas.

            Anyway…appreciate the conversation. I hope that as a nation we can find a way to overcome these issues so good health becomes entrenched as a right, just as it is in other similar wealthy countries.

  • Patricia

    Well I think that newer doctors who are brought into the systems from day one will have better thoughts about it. As it should be. I think docs are resenting that they are being brought to a level of “worker” like most other Americans are. Unfortunately they blame the idea of “Obamacare” rather than the systems that have been in place that make “Obamacare” necessary (and, um, other countries have unified healthcare for everyone and their societies are healthier than we are…stats for that are easily found).

    • J. Miller

      But didn’t you just above argue that the purpose of free medical care is not to make people healthier? “No, health insurance does not equal better health”, you admitted. So maybe it is other societal/cultural issues in those other countries which lead to healthier citizens.

      • Patricia

        You are purposely not trying to get the message but to argue. Statistically, healthcare does not make us healthier. Obviously health is something that needs a more holistic approach. However, if one has disease, one should be able to get treatment. Why should a poor person with diabetes not be able to get insulin? Why should someone in poverty have to lose her teeth because insurance for the poor won’t pay for saving and/or replacing a tooth?

  • HJ

    Doesn’t this study indicate that primary care isn’t as valuable as everyone thinks? Prevention doesn’t happen and outcomes aren’t any better.

    • Patricia

      Integrated care is what is needed. People with chronic conditions need to be treated. And prevention needs to swim upstream to the real causes of the American health problem in order to reduce healthcare costs.

  • buzzkillerjsmith

    Home insurance is a failure because it does not decrease the likelihood that your home will burn down. Sure it decreases the risk of financial ruin, but so what? The whole point of insurance is to make houses healthier and to decrease societal costs.

    Insane, right?

    Well that’s the argument we’re hearing from Dr. S. Medicaid expansion is mainly to help pts financially, everyone with an ounce of brains knows this. Apparently Dr. S. does not.

    Medicaid is pretty crappy insurance, known to be so. Many docs see Medicaid pts only if they feel they must for one reason or the other.

    But it gets worse. Two years? Two years is not time enough to show jack in terms of health status improvement.

    It gets still worse. I would submit that if we gave folks with good HI even better HI, their health status would not improve much if at all because of the simple fact that health care is only a small determinant of aggregate health. Certainly HC is life-saving for many persons, but we’re talking aggregates here. If we were serious about wanting to improve health outcomes instead of, and I’m talking ’bout you here Dr. S., bagging on poor people, we’d spend more time thinking and talking about the ineffective and expensive care that the rest of us get.

    But that’s not it is in the good old US of A. If you are poor, then you are fair game for those who just love to humiliate. People buying steak at Safeway get indignant in the checkout line about the single mom buying chips for her kids once in a while.

    Ignore the right-wing nutjob drooling on this issue and give poor people decent insurance so as to decrease the likelihood of their further financial distress.

    • J. Miller

      Does your home insurance cover routine everyday maintenance, “preventative care” and “routine screenings”, pay for routine care & maintenance supplies, etc? Do you get free annual “well house” checkups? If you completely neglect all basic maintenance on your home, basically letting it fall to bits, does your home insurance kick in and send teams of professionals around to fix it up for you “for free”?

      An example: the ceiling of a rental house I own got stained and moldy and started to crumble, it turns out it was because the gutters hadn’t been cleaned in god knows how long. Because that damage was caused by my own negligence, insurance didn’t cover the repair costs.

      Health insurance used to be more like home or car insurance, but it’s not anything of the sort anymore. So it’s ridiculous to compare the two. “Free health insurance” is now sold by most people, including those in government, as “making people healthier”, not “well it doesn’t do anything for their health but at least someone else picks up the tab for all the services they consume”.

      • buzzkillerjsmith

        Not your brother’s keeper I see. We seem to be at loggerheads. Basic health care should be a human right in this country, even if people don’t take care of their bodies. The simple reason for this is that people will engage in activities that you and I do not approve of. It will always be that way, and moreover, contrary to what you imply, incentives like checkups will not change this.

        Oh how wonderful it must be to sit on the high horse, watch the Fox News, and blame others for being human. The tight little Republican world.

        • Filo Bedo

          I think your definition of human rights and other people’s definition may be a bit different. When I think of human rights, I think of those in power leaving my children and those I love in peace, without the threat or fear of force, oppression, or tyranny. I think of boundaries.

          “The right to swing your fist ends where my nose begins.”

          The problem with the ACA and progressivism in general is that the “rights” of some are granted at the expense of the of others’. In other words, others’ boundaries are being violated in the name of _________. Sorry buzz, but rights are about boundaries, not health care.

          Moreover, to say health care is a right is to say that someone must provide that care. I could be wrong here, but neither you, I, nor anyone else in the free world (where people have rights) has to be a physician.

          • Patricia

            Don’t you consider the oppression of the poor, disenfranchised, women, Blacks…to be tyranny? And don’t you think the way corporations control every single movement we all make to be tyranny?
            Did you know that it is more expensive to live in poor rundown areas than it is to live in the lovely suburbs? I could go on, but I think if you engage in this discussions, as an educated person, perhaps you should read about these issues. Just my opinion.
            And if health care is a right and someone must provide it, it doesn’t mean that a person wouldn’t get paid. He/she would.

            Personally I would rather pay taxes that support a healthy and prosperous, actually fair country rather than the corporations (who don’t pay taxes by the way) and super/uber rich, and endless war (and the military industrial complex that Eisenhower warned us against). What we don’t know about all this is frightening.

          • Filo Bedo

            I do believe tyranny exists in all types of relationships from governing, to corporate, to personal. Don’t get me wrong, I do believe people need help and there should be resources available. I can only speak from personal experience and the experience of others I know that for the individual, personal responsibility is a much more effective antidote than dependence.

            It is great that you care and are crusading for the less fortunate. Even better if you are on the front lines of the effort, volunteering and advocating. But these issues of the poor you intelligently speak of… I don’t need to read about. I’ve been there. You read about them.

            Yes, someone would be paid if they were forced into medicine against their will. Boy would that make for a great health care system! There is a great blog about jaded med students. You should read it, then tell me if you think it would be a good idea to force this career on the unwilling. You can mandate all the great utopian ideas you like and hope all respond like good subjects, but life is not static and these kind of naive ideas will never account for the unintended results brought about by the free will of a dynamic human being.

            I’m no fan of the wars, the mega-corporations and banks, or the consolidation of wealth. I bet we agree on more problems than what you think, I just think we disagree on the root causes and their solutions.

          • Patricia

            At least we can agree one what we don’t like. And please don’t think I am naive I don’t at all believe the solution is easy. And I DO feel discouraged when I realize the depth of the problems (much of which lies in attitudes because if people changed those, change could happen fast)

            I know about these issues first hand as well. I also do like to read and am getting a higher education (which will undoubtedly keep me at the poverty level). I have volunteered etc etc. I don’t think it’s a big deal. But being a person who has had to receive benefits just to heat my house while raising a child with special needs, being a single mom..all that, I realized how insurmountable these problems are for individuals. And so I wanted to work FOR something rather than AGAINST something.

            I don’t think people should be forced into serving as doctors; that’s sort of silly. I only pointed out that doctors (et al) would still get paid. They would not be forced to work for free! The idea of “dependence” is an interesting one. How do we, as a society, create true equity and respect? That is the real question. If we have that, then I think things will change. Good health care for all is a great start.

          • Filo Bedo

            I truly appreciate your response Patricia. I do think there is a middle ground if you can get past the political and ideological nonsense.

            Well what can I say regarding your current situation? Not much considering I am not a single mom. But as I stated before, I was raised by a single mom; and taught what giving the best of yourself is all about by her. Children, especially, special needs children are a worthy cause I think everyone should get behind.

            How do we create as a society, true equity and respect? What do you mean exactly by true equity? How do you define that? Respect? I don’t see how this can be fully achieved. People can be selfish and mean. This is an element that will likely always exist. “Be the change you want to see in others.”

          • Patricia

            I am happy we are getting past our ideologies. Maybe it takes persistence and I guess if people want the same things.
            I think true equity has to come through law and policy. That we, as a culture (can be on small local levels and build to larger ones) need to make good health a priority. And we need to stop listening to politicians who con’t prove that they understand where the problems come from. Access to health care is only part of it.

            It would be so great if people could talk about creating health, true wealth and social equity rather than the myth that people are ripping off ‘the system’; because I am willing to bet anything that those who are doing that are wealthy corporate types stealing way way more than a couple welfare fakes.

            **shakes hands**

      • Dave

        Actually homeowners insurance does (can) cover most all of what you said. Ditto for car insurance. It’s all a matter of how big a premium you’re willing to pay, and whether or not the insurance company deems your house or car a good risk. You can buy maintenance policies for new and new-ish cars, though probably not for that clunker with 200k miles on it.

        Now, imagine that even routine maintenance varied wildly in price AND you were not given a quote in advance. What if that tune up could be $400 or $4000 and you have no way of knowing?
        The fact is that we’ve built our healthcare system around a third-party payer model, and there’s just no feasible way for anyone to self-insure anymore, especially the very poor. How else is someone who is Medicaid-eligible supposed to pay for care? Put $200-300 a month of their $1200 take-home pay into a HSA? Really? Pay the same for health insurance assuming they don’t have pre-existing conditions and can get it at all?
        I wouldn’t go so far to say that we have a right to healthcare, but I do believe we have an ethical responsibility as a flourishing modern society to provide it for those in need. We have no problem spending 10x as much on wars over the deaths of 3,000 people, so money shouldn’t be an issue when 20 times as many people are being killed each year.

        • M.K.C.

          Neither home nor car insurance are government-mandated to cover all routine repairs and maintenance costs.

  • usvietnamvet

    Why does medicaid give better services and coverage then medicare when we pay for medicare? Someone on medicaid can see doctors that people on medicare can’t. Also it’s a shame neither program allows things such as acupuncture, massage therapy, chiropractic (all of which have been extremely helpful for me and other people with chronic conditions).

    • Patricia

      Totally agree. Wouldn’t it be great if our society could recognize that universal health would benefit us all? And that include monetary rewards. I personally know of a creative, gifted, talented and giving individual who died because she was poor. She had “free-clinic” care which was pretty bad. The result: she died. Her children are on services and the whole family is devastated and under-productive. (Personally I don’t see productivity as a valuable measure but some do).

  • Rick Lundgren

    The Oregon Health Insurance Experiment (OHIE), a randomized controlled trial (RCT) of Medicaid, failed to show statistically significant improvements in physical health; some have argued that this rules out the possibility of large effects. However, the results are not as precisely estimated as expected from an RCT of its size (12,229 individuals) because of large crossover between treatment and control groups.

    The Experiment’s low precision is apparent in the wide confidence intervals reported. For example, the 95% confidence interval around the estimated effect of Medicaid on the probability of elevated blood pressure spans a reduction of 44% to an increase of 28%.
    We simulated the Experiment’s power to detect physical health effects of various sizes and the sample size required to detect effects sizes with 80% power. As shown in the table, it is very underpowered to detect clinically meaningful effects of Medicaid on the reported physical health outcomes. For example, the study had only 39.3% power to detect a 30% reduction in subjects with elevated blood pressure. It would have required 36,100 participants to detect it at 80% power. Moreover, such a result is substantially more than could be expected from the application of health insurance.

    http://theincidentaleconomist.com/wordpress/page/2/

  • maga_bee

    One thing that bothered me was the idea that two years of a huge program can indicate failure. When we’re talking about one’s health, we aren’t just talking about their blood levels. We are talking about education as well. Learning how to take care of yourself properly when you’ve been taken care of by ER docs your entire life doesn’t come instinctively.

    I grew up in poverty, and in addition to all the health care services you just don’t get as a poor person, there is a general distrust and/or intimidation when it comes to doctors in the poor communities. I remember my parents being talked down to by medical professionals, I remember being told to “keep my head down and shut up” before walking into a doctor’s office, and I remember more than a thousand times family members repeating the poor person’s slogan: “He doesn’t know what he’s talking about.”

    I’m citing anecdotes of course, but my experiences are far from abnormal. My point is simply to point out an underlying lack of trust and education that needs to be addressed before a blood level is going to show results.

    How long does it take a person to break a habit? It’s easy to say “You need to stop smoking/eating boxed crap/using so much salt,” but very difficult to actually put that into action if you’ve lived your entire life doing those exact things.

    I lived on canned vegetables and boxed everything. I love fried foods and have cravings for fast food several times a week. I’m extremely lucky (at 36 years old) to have never suffered any health problems, including weight problems. But due to my husband’s health issues, I can’t eat like that. We’ve been together for 10 years and I still struggle with my eating habits, even though I desperately want to eat nutritiously so my family will stay healthy and my children will learn what that means. I have all the motivation in the world, but it is so hard to kick those habits.

    Point? Citing a failure after a mere two years of a problem so massive and pervasive is a joke.