Monday, April 23, 2018
Health

Oregon Medicaid lottery holds lessons for nation

PORTLAND, Ore.

When Wendy Parris shattered her ankle, the emergency room put it in an air cast and sent her on her way. Because she had no insurance, doctors did not operate to fix it. A mother of six, Parris hobbled around for four years, pained by the foot, becoming less mobile and gaining weight.

But in 2008, Oregon opened its Medicaid rolls to some working-age adults living in poverty, like Parris. Lacking the money to cover everyone, the state established a lottery, and Parris was one of the 89,824 residents who entered in the hope of winning insurance.

With that lottery, Oregon became a laboratory for studying the effects of extending health insurance to people who previously did not have it. Health economists say the state has become the single best place to study a question at the center of debate in Washington now that the Supreme Court has ruled on the constitutionality of President Barack Obama's health care law: What are the costs and benefits of coverage?

In a continuing study, an all-star group of researchers following Parris and tens of thousands of other Oregonians has found that gaining insurance makes people feel healthier, happier and more financially stable. The insured also spend more on health care, dashing some hopes of preventive-medicine advocates who have argued that coverage can save money — by keeping people out of emergency rooms, for instance. In Oregon, the newly insured spent an average of $778 a year, or 25 percent, more on health care than those who did not win insurance.

For the nation, the lesson appears to be mixed. Expanded coverage brings large benefits to many people, but it is also more likely to increase a stretched federal government's long-term budget responsibilities.

The newly insured were more likely to describe their health as good and to say that their health was getting better, according to self-reported data that researchers are now combining with objective measurements for a deeper follow-up study. The uninsured reported being in worse physical and mental shape and were less likely to describe themselves as happy.

Getting insurance also had powerful financial effects, the study showed. The insured were 25 percent less likely to have an unpaid medical bill sent to a collection agency and 40 percent less likely to borrow money or skip paying other bills in order to cover their medical costs.

"I feel like a different person," said John Bell, a stay-at-home father who won the insurance lottery.

"I was pretty grumpy all the time before."

Before winning the lottery, Bell filed for bankruptcy after emergency surgery to remove kidney stones left him with a $6,000 bill that he and his wife could not pay, he said. Today, Bell has a primary care physician who has encouraged him to lose weight and improve his diet to help control his diabetes.

The Oregon Health Study has won academic attention both because of the pedigree of the researchers — including Joseph P. Newhouse, who designed the renowned RAND Health Insurance Experiment in the 1970s, and Amy Finkelstein, the most recent winner of the John Bates Clark Medal, an economic prize considered second only to the Nobel — and the distinct nature of the state's health insurance lottery. By assigning coverage randomly, Oregon gave researchers more confidence that they had teased out the true effects of insurance, and had not been fooled by other differences between the insured and the uninsured.

"The study put to rest two incorrect arguments that persisted because of an absence of evidence," said Katherine Baicker, a Harvard economist who worked on the study and served as an economic adviser to President George W. Bush.

"The first is that Medicaid doesn't do anything for people, because it's bad insurance or because the uninsured have other ways of getting care," Baicker said. "The second is that Medicaid coverage saves money" by increasing preventive care, for instance.

"It's up to society to determine whether it's worth the cost," she added.

Discussions with 17 insured and uninsured participants in the Oregon Health Study illuminated how coverage changed and did not change their lives. Many described poverty and its attending problems, not health care, as their major challenge. (The Affordable Care Act, Obama's health care law, requires states, in 2014, to extend Medicaid eligibility to all adults within 133 percent of the poverty line, which is currently $11,170 for a household of one and $23,050 for a household of four.) A handful said that they were not overly bothered by their lack of coverage, or that winning Medicaid had not had much of an effect.

But many, including Parris and Bell, said Medicaid had made a significant — even transformative — difference in their lives.

Parris got surgery for her foot and other care. She is also getting spinal surgery. Doctors have helped her address her depression, triggered by the death of one of her children. Her weight has come back down, and her mobility is far better.

"It saved my life," she said.

Most of the uninsured described their lack of coverage as a profound problem.

For instance, a year ago, Samantha Kious, a hairstylist, went to Planned Parenthood to seek birth control medication to manage her polycystic ovary syndrome, a common hormonal imbalance.

Kious, 24, who also has depression and Crohn's disease, a bowel condition, makes only $1,000 to $1,200 a month and cannot afford insurance. The clinic performed some tests and prescribed Kious the pills, but also told her that she had Stage 2 cervical cancer. As of now, the condition remains untreated. She and her boyfriend even considered conceiving a child so that she would automatically qualify for Medicaid.

"It's scary for me, having cancer and knowing I can't do anything about it," said Kious, her hair in an elaborate plait. "It's an I-don't-know-when-my-next-meal-will-be sort of thing. It's really difficult because health problems make you scared and emotional."

Interviews with study participants showed that the insured and the uninsured got health care in significantly different ways. Lottery winners tended to have a primary care physician who saw them regularly and helped them navigate the health care system. Few of the uninsured saw doctors regularly, and none said that they had regular health examinations.

Some sought care from free clinics or charity hospital programs. But they said it was difficult to know when and where such programs were available and sometimes how to use them. You might have to bring certain paperwork to prove your poverty, for instance. Child care could be a problem. You might show up on the wrong day.

"You've got to be clearheaded" to find free care, said Cynthia Robbins, 57, who is unemployed and won insurance. When she was uninsured she neglected the effects of her diabetes — including problems with circulation in her feet that resulted in the amputation of a toe. "When you're in the middle of a crisis, you're not going to be filling out forms."

The uninsured described borrowing medication from family members and friends, taking it every other day, and asking doctors to diagnose multiple conditions and write multiple prescriptions on a single visit. The insured said they had largely abandoned such strategies.

Nearly all of the uninsured also described how avoiding doctors to save money resulted in trips to the emergency room. (Unnecessary or preventable emergency room use costs some $38 billion a year, researchers estimate.)

"I think the E.R. doctors now know me by name," said Kious, the hairdresser. "But that's the only thing you can do. You wait until you can't bear it anymore."

Study participants described coverage as no magic bullet for a person living under or near the poverty line, but as something that tended to make life easier.

"It's a weight off your shoulders when you feel like you can go to the doctor like everybody else," said Robin Baros, 51, who won insurance. "And when you have insurance, you feel healthier. You want to take care of yourself. You've got your regular visits that you can go to."

Not having insurance "affects your whole life," said Christine Toman, 61, who has a chronic pulmonary condition and hepatitis C and did not win coverage. "I went to work. I paid my bills. And now I feel like a hopeless, hopeless old woman that's in the way, and it's sad to feel like that. I'd like to die with some pride."

Toman, in a husky voice and a soft wheeze as she labored to breathe, said that she occasionally goes to the emergency room when her conditions became acute. But she generally just forgoes care.

Comments

Veteran who survived blast receives unusual penis transplant

WASHINGTON — A veteran who lost his genitals from a blast in Afghanistan has received the world’s most extensive penis transplant, and doctors said Monday he’s recovering well and expected to leave the hospital this week. Saying they wanted to addres...
Updated: 3 hours ago
Do not eat any romaine lettuce, the CDC warns

Do not eat any romaine lettuce, the CDC warns

Public health officials are now telling consumers to avoid all types of romaine lettuce because of an E. coli outbreak linked to the vegetable that has spread to at least 16 states and sickened at least 60 people, including eight inmates at an Alask...
Published: 04/20/18
Florida hits a milestone: More than 100,000 people are registered to use medical marijuana here

Florida hits a milestone: More than 100,000 people are registered to use medical marijuana here

Florida has hit a milestone of sorts as it slowly moves toward wider availability of medical marijuana.The number of patients in the state who are registered to use the substance has surpassed 100,000 for the first time, according to Florida Departme...
Published: 04/20/18
Florida Hospital Carrollwood spending $17.5 million to expand emergency department

Florida Hospital Carrollwood spending $17.5 million to expand emergency department

Florida Hospital Carrollwood is expanding its emergency department. The hospital, 7171 North Dale Mabry Highway in Tampa, is spending $17.5 million to add 15 new private treatment rooms, new pediatric rooms and waiting areas, and new technology, acco...
Published: 04/18/18
Barbara Bush’s end-of-life decision stirs debate over ‘comfort care’

Barbara Bush’s end-of-life decision stirs debate over ‘comfort care’

As she nears death at age 92, former first lady Barbara Bush’s announcement that she is seeking "comfort care" is shining a light — and stirring debate — on what it means to stop trying to fight terminal illness.Bush, the wife of former President Geo...
Published: 04/17/18
Preparing for the worst, staffers at Johns Hopkins All Children’s learn through simulation

Preparing for the worst, staffers at Johns Hopkins All Children’s learn through simulation

When the patient got violent, Dr. Michelle Hidalgo didn’t have time to think. She had to react. The woman was moving strangely and seemed erratic. Hidalgo had to make a tough call — it was time to physically restrain her for everyone’s safety.Then th...
Published: 04/16/18
Updated: 04/17/18

Lung cancer patients live longer with immune therapy

The odds of survival can greatly improve for people with the most common type of lung cancer if, along with the usual chemotherapy, they are also given a drug that activates the immune system, a major new study has shown.The findings should change me...
Published: 04/16/18
Thousands of pounds of prepackaged salad mixes may have been tainted with E. coli, officials say

Thousands of pounds of prepackaged salad mixes may have been tainted with E. coli, officials say

A Pennsylvania food manufacturer is recalling 8, 757 pounds of ready-to-eat salad products following an E. coli outbreak that has spread to several states and sickened dozens of people.Fresh food Manufacturing Co., based in Freedom, Pennsylvania, is ...
Published: 04/15/18
St. Anthony’s Cancer Center installs bell dedicated to survivors

St. Anthony’s Cancer Center installs bell dedicated to survivors

ST. PETERSBURGSister Mary McNally, vice president of mission at St. Anthony’s Hospital, stood in front of a room of cancer survivors to unveil a silver bell surrounded by butterfly stickers mounted to the wall of the Cancer Center lobby. "So often pe...
Published: 04/13/18
Hand dryers could leave your hands dirtier than you think

Hand dryers could leave your hands dirtier than you think

Washing your hands after you use the bathroom is a good idea. But using a public dryer could undo all that hard work, according to a new study.A study, published in the journal Applied and Environmental Microbiology, examined 36 men’s and women’s bat...
Published: 04/13/18