A New Low in Health Care Rhetoric

By Matt Taibbi, Rolling Stone

08 January 14

thought we'd heard it all when Sarah Palin compared having to pay taxes for someone else's health care to slavery, but old friend and Ayn Rand devotee Megan McArdle may have one-upped her.

Like the legalization debate, which is meaningless to anyone who's never actually been at risk of being arrested on a drug charge, health care reform is just another annoying tax-day line item if you've never had to worry about not being insured.

If you're that kind of person, I guess it's possible to forget that the whole point of even trying health care reform was to correct a proved-broken system that left a huge plurality of the population living for decades in a kind of permanent mental health crisis, with millions laboring under the stress of knowing that they might be one serious illness away from bankruptcy, foreclosure, even homelessness (and historically, this has been true even of people with insurance).

That would seem like an important problem to fix, but of course one has the right not to care about that if one chooses. And McArdle chooses. Her January 2nd column in Bloomberg, "Another Problem Obamacare Won't Solve: Health Costs," goes beyond saying the Affordable Care Act is inefficient and dysfunctional, and asserts that offering those millions of previously uninsured people the hope of coverage is of no benefit to anyone, even to them. Why? Apparently, because the poor and sick are going to stay that way no matter what us with-it healthy people do to try to help them.

The piece begins by taking on one of the sacred cows of health reform, promising to show that the ACA will not reduce the high costs of emergency room visits:

Does giving people health insurance help control costs?

Conventional wisdom holds that it should, by diverting them from expensive emergency room use to less-expensive visits to doctors and nurse practitioners. This argument was very popular with advocates for health reform in 2009, and it remains a sort of folk wisdom among educated people; I've heard some version of this argument in virtually every discussion I've had about health care in the last decade.

McArdle is leaning here on data from an investigation done in Oregon, in which a control group of 10,000 new Medicaid enrollees was monitored, beginning in 2008. The results of the study, released last Thursday in the journal Science, showed a 40 percent increase in ER visits among those new low-income enrollees during the control period. Megan couldn't have been happier about the implications of this study:

Does giving people Medicaid drive ER usage up, or down?

The answer, it turns out, is "up." People who got access to Medicaid used doctors more than people who didn't. But they also used the ER more.

There's a little bit of data-cherry-picking going on here. As the Washington Post noted a day after McArdle ran her piece, the surge in ER visits mostly took place right after the new enrollees got their insurance.

Subsequently, the situation improved, thanks to a program in which community health workers stationed at hospitals simply told people who showed up at the ER that they had the option to go to "less costly settings," i.e. primary care doctors. As a result, ER visits soon began to decline. Wrote the Post's Sarah Kliff:

Emergency-department spending decreased by 18 percent in Oregon's Medicaid program, when the 2013 study period was compared to a 2011 benchmark . . . State health officials' data show that much of the reduction has come from moving primary care outside the emergency department. So to sum up: A whole bunch of people were handed health insurance in 2008 when the state of Oregon expanded its Medicaid enrollment. In the first few years after these people got insurance, they went to emergency rooms in large numbers, probably because they'd been living their whole lives in a system where the ER is the only place where they couldn't be turned away for having no coverage/money.

Later, the state started posting the equivalent of health-care crossing guards in hospitals, whose entire job it was to explain to the low-income newly-insured that they could actually go to see a doctor somewhere outside of an emergency room without being thrown on the street. Shockingly, this resulted in a decrease in ER visits.

Still, that initial 40 percent surge in ER visits was undeniably significant, and it's no surprise that health care opponents like McArdle jumped all over it. But in this case she went further, digging into other parts of the study.

Specifically, she pointed to data showing that the Oregon group didn't show significant improvement in cholesterol, blood pressure and diabetes rates (although enrollees did show lower rates of depression).

Her take on this tiny initial sample of reform data: Just a few years into having access to primary care doctors, people are not healthier according to a few markers. Therefore, that proves it! Giving poor people health insurance achieves nothing.

After all, she argues, the low-income obese are not suddenly going to start running marathons, just because some doctor tells them to. They were obese in the first place for a reason!

Here's how she put it:

Obamacare mostly solved a quite different problem: the fact that health insurance and health care are expensive. It probably isn't going to lower costs, or dramatically alter mortality rates, or turn obese diabetics into marathoners. On the other hand, it probably will improve the financial stability of a lot of low-income households, while raising costs (and taxes) on the more affluent.

She went on:

As [MIT professor Amy] Finkelstein said to me: For an economist, insurance is a financial product, health insurance as much as life or auto insurance. Auto insurance probably doesn't improve your driving much, but it does protect your assets if you're in an accident.

Look, I've never been a fan of the Affordable Care Act. I thought it was a flawed bill, rushed into being for political reasons, that was destined to leave a huge chunk of our health care problems unsolved, in the process creating complex new burdens for taxpayers while preserving regulatory and financial handouts to the predatory health insurance industry.

So I get saying the ACA is expensive and won't reduce costs. Thanks to the piles of subsidies they left in the bill and a slew of other problems, I might even agree.

But you'd have to be a complete sociopath to assert that expanding access to health care to millions of people doesn't improve their health – and that the only tangible benefit of health care reform, in fact, will be taking money out of the pockets of hardworking taxpayers like yourself, and redistributing it to the incorrigibly unhealthy.

Apparently low-income Americans will have no problem taking money from the affluent – the law will improve their "financial stability" – but they won't get healthier even with new access to doctors because, hey, having auto insurance doesn't make you a better driver, right? (She's wrong even within that metaphor – I think anyone who's even been docked points for a speeding ticket has driven more slowly the next time out of the garage – but whatever).

This is sort of like that old argument that suffrage for blacks or women was pointless, because people like that wouldn't know what to do with the vote. And if nobody's getting healthier, well, then, the whole thing is just a waste of money. Specifically, Megan's money. So why bother?

What is it about the health care debate that makes people so crazy?