Down in Flames

The GOP's attempts to repeal and replace Obamacare went down in flames. Part of the problem is that GOP senators have differing opinions on what federal intervention into healthcare should look like (they didn't act with the hive mind of Democrats in 2009-2010). As I've noted, the GOP failure to repeal and replace is bad in the political short term, but over the mid-term, it will highlight the reality that Obamacare is collapsing before our eyes. Since the Democrats don't want to participate in any realistic fixes to the failing program, it might be better to allow it to fail—putting pressure on everyone in Washington to do something.

Then again, with the Dems dishonestly suggesting that any changes to Obamacare (by the GOP) will result in the "deaths of millions" and their stated objective of resisting Donald Trump in every way possible, it's pretty hard to see an effective bi-partisan bill emerging.

The Obamacare debate is emblematic of most in Washington—an honest attempt to reduce costs and improve effectiveness, followed by demagoguery and fear mongering at any attempt to reduce costs and improve effectiveness. It is fed by inaccurate and misleading claims about coverage and costs.

Shikha Dalmia writes:

Medicaid provides health care to 75 million Americans. [In other words, about 1/4 of the population gets "free" medical coverage paid for by the rest of us]. It's also a hideously expensive program that is at the center of the raging health-care debate in Washington. Republicans want to scale back the program, and Democrats warn that doing so will cause nothing short of mass death.

But that is not a credible—or responsible—claim.

ObamaCare extended Medicaid eligibility to able-bodied adults at up to 138 percent of the poverty level. To do this, the federal government promised to pick up 100 percent of the tab for the first three years, and then 90 percent in perpetuity in participating states. Republicans want to trim back Medicaid eligibility to the pre-ObamaCare days, when "only" the poor, children, the disabled, the elderly, and pregnant women qualified.

Conservatives also want to take the opportunity to fundamentally reform the program, which consumed half of most state budgets and a tenth of the federal budget even before the ObamaCare expansion. To this end, Republicans want Uncle Sam to stop handing states on average 50 cents for every Medicaid dollar they spend and instead give them a fixed lump sum on a per-patient basis and tie its growth to general inflation.

But GOP attempts at reform shift power from Big Intrusive Government (B.I.G.) to the states. That is anathema for almost all Democrats.

But ... but ... but, it's much better for poor people and others to have coverage under medicaid because—they don't die! The implication of this gross exaggeration is that health outcomes are better under Obamacare/Medicaid. But they aren't. Again from Dalmia:

Medicaid is perhaps the civilized world's worst program. It costs just as much as private plans—about $7,000 per patient—but produces worse outcomes, including higher mortality, than private coverage. So given that one of ObamaCare's dirty little secrets is that many of its Medicaid enrollees are folks kicked off their private plans due to the Medicaid expansion, the law may have actually cost—rather than saved—lives in this cohort.

But what about the uninsured? Extending Medicaid to these people improved their health and diminished mortality, right? Wrong. Plenty of reputable studies [links to studies in original] suggest that this might not be the case:

• A 2010 study by the University of Virginia of 893,658 patients in the university hospital found that individuals on Medicaid had the worst post-surgery survival rate of any patients, including the uninsured, after controlling for age, health status, income, and other relevant factors.
• A 2011 Journal of Heart and Lung study found that of 11,385 patients undergoing lung transplants, Medicaid patients were 8.1 percent less likely to survive than the uninsured after 10 years. They also found Medicaid insurance was a significant predictor of death within three years, after controlling for other clinical factors.
• And then there is the famous 2013 Oregon study — the closest thing to a lab experiment in the real world — co-authored by ObamaCare architect Jonathan Gruber. It contrasted uninsured patients who were randomly assigned to Medicaid with those who remained uninsured and found that the Medicaid patients did not have significantly better outcomes for diabetes, high cholesterol, high blood pressure, and even mortality.

... even if Medicaid's mortality outcomes were somewhat better for the uninsured, it would still not necessarily follow that extending the program would save lives on balance—or that eliminating the program would do the reverse. In a world with finite resources, one also has to consider the opportunity costs or other ways of spending that may potentially save more lives.

Indeed, a 2016 study in the journal Health Affairs found that states that spent a smaller portion of their budgets on Medicaid and Medicare than on social programs such as housing, nutrition, and even public transportation, showed "significant" gains on a myriad of health factors, including mortality, over states that did the reverse. It is possible that this is purely coincidental. But it may also be the case that these programs improved general quality of life and lowered stress levels, thus bettering baseline health and preventing people from falling prey to life-sapping illnesses in the first place.

And what holds true for state-level spending might be doubly true for individuals spending out-of-pocket.

But all of this requires critical thinking and that appears to be in very short supply among most Dems and more than a few in the GOP. The studies are dismissed because they don't conform to the narrative. Any attempt to reduce federal influence in medical care is dismissed because—B.I.G. is a holy writ among progressives and apparently, is accepted as a constant by too many in the GOP.

P.J. O’Rourk once said:  “The Democrats are the party that says government will make you smarter, taller, richer, and remove the crabgrass on your lawn. The Republicans are the party that says government doesn’t work and then they get elected and prove it.”

POSTSCRIPT:
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I'll be on vacation for the next week. See you when I return.