Does Medicaid Actually Improve Health?

Ashish Jha: 00:00:07

Hey everybody. Ashish Jha here from Providence, Rhode Island on a hot, sunny afternoon, and we are back with another episode of a moment in health, a podcast where we talk about one data point, we discuss one study, and then we ask a question, and the data point I'm going to jump right into it this week, a data point that I want to talk about is 700 that's the number of rural hospitals that are at risk of closure, according to a new analysis done by an organization called the Center for Healthcare Quality and payment reform. These guys sort of track health reform across America, and their analysis suggests that there are almost 700 rural hospitals that are at risk of closure. Over 300 of them are at immediate risk of closing because of the severity of their financial problems. So let's take a minute to talk about why rural hospitals are so important and why they're at risk of closure and what we can do about it. Well, they're important for obvious reasons. They often serve as the only source of clinical service, medical service for people living in rural areas across America, and when they close, people have to go substantially longer distances to get health care. Now, why are they at financial risk? In my mind, there are two or three sets of issues that are particularly important. One is people living in rural areas tend to have higher health needs, so their costs of taking care of those people can be higher. Those people also tend to be less insured, and that obviously means that a lot of hospitals are taking care of uninsured people and not getting reimbursed. And then costs can be higher because it can be hard to recruit people to those areas. You often have to give substantial financial bonuses to get doctors and nurses who work in rural areas. All of those put together, really make an important difference. Couple of more points. If you look at the top five states at risk of closing they are Kansas, Oklahoma, Alabama, Texas and

Ashish Jha: 00:02:09

Mississippi, one of the things you'll recognize is four of those five states, Kansas, Alabama, Texas and Mississippi have not expanded Medicaid, and that, in my view, creates substantial risk, because that means a lot more uninsured in those people populations in those states, and that it puts more pressure on these rural hospitals. And the final point is, depending on what happens in Washington, if we see further erosion of the Medicaid program, with more people losing health insurance, you are going to see more pressure on rural hospitals, and that's going to, I think, continue to make life much harder for people in rural areas. Finally, what do we need to do? There are a lot of policy solutions and ideas out on the in Washington, including creating funds for rural hospitals. I certainly think insurance expansion is absolutely critical. That's going to be really important, and then making sure that we're actually paying rural hospitals at hospitals adequately for the extra set of services that they need to provide, and the difficulty of providing care in rural areas, all of that is going to be important. So that's your data point of the day of the week. 700 rural hospitals at risk, more than 300 at immediate risk of shutting down. You

Ashish Jha: 00:03:25

all right, I want to move on now to talking about a study, the study of the week. And the study of the week comes from the New England Journal of Medicine, from the June 21 issue of the New England Journal, and it is called, and here's my PRONUNCIATION challenge, but I'm going to do it. It's called orphogliperon, an oral small molecule GLP one receptor agonist in early type two diabetes. All right, so this is pretty exciting stuff, in my mind. This is about GLP ones. You've all heard about GLP ones. GLP ones include drugs like ozempic and Zep bound. There are a couple. Those are the two main ones that are out there that people know. They are incredible for weight loss. They're they were first approved for diabetes. They're both injection drugs, drugs you have to inject yourself with once a week. Injections create a few problems. One is they make the drugs much more expensive to make. A lot of people don't like needles and injecting themselves, and they're just much harder to make. And therefore there have been limited supply, and it's been expensive. We've all been waiting for oral GLP ones, and now you've got a new clinical trial in the New England Journal focused on people with early diabetes, people who are not on medicines but have diabetes, and an oral GLP one. And basically, the study is a randomized control trial that finds the following. Turns out, GLP ones are really good for diabetes control. People who were on the highest dose of this drug, or for glypron, saw a very substantial decrease in their hemoglobin. Anyone see that's their blood sugar control, about one and a half percentage point. Points, that's a lot. A lot of those people who had poor diabetes control got it under control with this drug. But the weight loss was also pretty interesting, and I think is worth taking a minute to talk about. What you saw is people who are on the highest doses of this drug saw about a seven and a half to 8% decrease in their body weight. So

Ashish Jha: 00:05:21

that would mean that somebody who might have been 200 pounds would be down to about 185 that's not quite as much as what we see with ozempic, not quite as much, definitely not as much as we see with Sep bound. But given that it's an oral drug, it's still pretty impressive weight loss and really valuable. So that's your study. Why is it so important and interesting? Because I think getting an oral GLP one will substantially lower the cost of the drug production. That doesn't necessarily mean it'll lower the cost of that consumers have to pay, but it is a nice option. Obviously, it'll expand opportunities for a lot more people who don't want to do injections, and I think it'll just make it more, make it easier to make this a widely used drug as well. So that is your study of the week.

Ashish Jha: 00:06:11

All right, now, for our one question of the week, and for this one, we have a very special guest, and we're doing this by zoom with Michael cannon. Many of you know Michael. He is the director of health policy studies at the Cato Institute. He was formerly a domestic policy analyst at the US Senate Republican policy committee. And he has been somebody who has written quite extensively about health insurance, health care in general, but particularly around Medicaid. All right, he's probably written about lots of other things, as much as Medicaid, but it's the one place where, let's just say, I'm not sure that we always see the world in exactly the same way. And as many of you know, if you've listened to me before, I have talked about the importance of expanding health insurance, and have very much included Medicaid as part of that. And so I thought I would have Michael on the show. So first of all, Michael, thank you in a huge, huge way, for coming on and willing to

Michael Cannon: 00:07:01

chat with me. Thanks for having me. It's great to be here. Awesome.

Ashish Jha: 00:07:05

So the question I have for you is, what is your assessment on whether Medicaid improves people's health? Does giving somebody who's uninsured Medicaid, is that good for their health, or do we think it's not good for their health? What do we know? What's your best assessment of the literature? So a

Unknown: 00:07:26

lot of people would say, yeah, obviously it improves their health. But my take on this, my read up the available evidence, is that it might improve health on average, and I hope that it does, but we really don't know, and there's a lot of evidence that suggests, hey, those health improvements that you expect to flow from spending more money on Medicaid maybe aren't there.

Ashish Jha: 00:07:50

Okay, so expand on that. Obviously, the best study, in some ways, arguably, to date, was a randomized trial of the Oregon Health Insurance experiment that did not seem to show much of an impact at a at a population level, but there's been all sorts of other studies of insurance expansion, even some other analyzes of the Oregon Health Insurance experiment. So tell me, as you look at the broad set of data on insurance, what makes you skeptical, if I can use that word that that Medicaid may not actually be having much of an impact

Unknown: 00:08:25

on people's health. So this is a public health podcast, so let me put this in a provocative way. It gets pretty complex, but I'm going to put in a provocative way, and maybe we'll be able to get a little bit into the complexity. So let's say you have a theory that Medicaid causes better health. You know, RFK Jr has a theory that vaccines cause autism. The studies that cast out on your theory are actually stronger than the studies that cast doubt on his theory. That's because the studies that cast out on his theory are observational studies, which are not as strong as randomized, controlled trials like the Oregon Health Insurance experiment to cast doubt on your theory. Now if it's but what this means is, if you think the evidence is strong enough to reject his theory, but not strong enough to reject yours, then you might be doing what scientists accuse RFK of doing, which is rejecting science in favor of like some other method of choosing what to believe. Now that doesn't mean he's right. It doesn't mean you're wrong. It does mean that these things are complex, and you should allow that you might be wrong, and you should support collecting more and more reliable evidence on the effect of Medicaid on health, because we need more evidence if we're going to be and more reliable evidence if we're going to be able to answer that question.

Ashish Jha: 00:09:44

All right, I like where this turned all sudden, Michael, but let me, let me push you a little bit on this. So question for you as a clarifying point, do you think the issue is that you're not convinced the data shows Medicaid improves health, or do you not? Are you not convinced that health in. Insurance more broadly improves health. Is your is your questioning of the evidence or your reading of the evidence broader to all health insurance, or is it just limited to Medicaid?

Unknown: 00:10:11

Well, they relate to one another, because what Medicaid purchases and what health insurance purchases is medical care and and so it also relates to the question of what situations does medical care improve health. And there are lots of observational studies on Medicaid impact on health. There is one randomized controlled trial of Medicaid impact on health. The observational studies tend to show that Medicaid does improve health, at least for certain populations and sometimes for broad populations. But there are other studies that show no, you know, no effect, some of the studies we don't even know about because of publication bias, and some studies that show maybe in some ways, Medicaid harms health, but they're all observational. And the the best study available is the the Oregon Health Insurance experiment, a randomized, controlled trial. It's a it's a better study because it controls for variables that those other studies can't control for. And it's not a perfect study. I would prefer that it'd be bigger but but it found no discernible impact of Medicaid on physical health outcomes. So Medicaid enrolling has got a lot more medical care, but there was no discernible improvement in the measures of physical health outcomes that they use. We should have been susceptible to treatment in a two year period, like hypertension, any sort of so. So your question was about is it, is it Medicaid or health insurance? Broadly, it is about Medicaid, but also the literature on health insurance broadly informs this question, because another randomized controlled experiment that looked at health insurance rather broadly, rather than Medicaid, was the RAND health insurance experiment from the 1970s and the 1980s and what it found was people with more health insurance got more medical care, but that medical care did not appear to make them healthier. So results from the Medicaid the Oregon Health Insurance experiment, which was a Medicaid specific

Unknown: 00:12:14

study, are consistent with other randomized controlled trials from the RAND health insurance experiment to trials in Ghana and India that show large variations in health spending due to health subsidies or health insurance do not deliver discernible improvements in health which, to me, just says, Hey folks back up. You know we have, there's a lot we appear not to know about the relationship of health insurance and medical consumption to

Ashish Jha: 00:12:44

health? Yep. Okay, fantastic. So I, look, I largely agree with almost everything you just said, and certainly the data from other countries has also shown that insurance expansion to itself doesn't always necessarily lead to better health, though. I think for me, the mental model has been that in a lot of places, the quality of care is so bad that if you get people access to relatively mediocre quality of care, you're not necessarily too much for their health. Let me ask you the last part of this question, then, which is, what is the data? So two things I guess, are related, what is the data you would want to see more of that's kind of feasible in the upcoming time period. And what should policymakers do in this moment where you're saying there's some uncertainty about how much Medicaid really improves people's health, or just health insurance improves people's health? What should policymakers be doing around insurance expansion?

Unknown: 00:13:35

So since at least 2013 and maybe even earlier than that, I haven't found evidence of me calling for this earlier than 2013 but maybe I did. I have been arguing to policymakers at the federal level and at the state level, don't expand Medicaid measure Medicaid to see what we're getting for all the money that we're spending on that program, because and the Oregon Health Insurance experiment happened by accident. That was they were just going to give me Medicaid spots by lottery. And some very, very smart economists said, Wait a second, this randomization, let us study that. But never has the federal government said, You know what? We're going to make sure we're spending this money wisely by actually measuring what we get for the money we're spending? That's what they should what Congress should have been doing, rather than expanding the Medicaid program the way that it did in the Affordable Care Act. And and it is, it is weird that the government has never asked that question in any sort of a serious way. I mean, I know government, it's government. It wastes lots of money, yeah, but from 1966 until today, the federal government has spent about $45 trillion on the Medicare program and the Medicaid program without ever trying to answer this question about, what are we getting for our for all the money we're spending? So that's what we should be doing, and it's not just med. Decade. You know, one of those economists who did the Oregon Health Insurance experiment, Amy Finkelstein, along with Robin McKnight, did a study that found no discernible impact of Medicare on elderly mortality in the first 10 years of its operation. So now observational study, but it also tends to corroborate what the randomized controlled trials find, which is that at the margin, subsidizing healthcare does not appear to improve health. So I think that what Congress should be doing is and what states should be doing is, not throwing more money at this problem, but measuring

Unknown: 00:15:32

what we're getting for the money we're already spending. And it's weird that they haven't done that yet, and it's weird that instead of people, the people who disagree with me about their interpretation of how to interpret the data on Medicaid and health that, they just say, no, no, no, ignore the Oregon Health Insurance experiment. We know that Medicaid works. It's weird that they're not joining my call for more and larger randomized, controlled trials of the health impacts of Medicaid.

Ashish Jha: 00:16:03

All right, Michael, I've gone well beyond my one question, but let me see if I can summarize this. So first of all, I I am. I'm one of those people who thinks that the amount of observational data we have, the trends that we saw in the Oregon Health Insurance experiment suggest and some reanalyses of the Oregon Health Insurance experiment suggests pretty strongly, in my view, and this is a place where we could absolutely disagree, that that health insurance expansion almost surely does improve people's health. Your point of better data, more data on this, especially for programs where we're spending literally hundreds of billions of dollars a year, is totally well taken. So maybe what we can do is we can agree on we need to be setting this a lot more carefully, to get more precise on who benefits how much under what circumstances, and we can disagree on whether you expand until then or you wait until you get more data. But your your point here has been really terrific, and I just want to say thank you for taking the time to chat with me again. I feel like I've overstayed my welcome on this conversation, because it was supposed to be short and sweet, and I promised you be a very brief conversation, but you were terrific, and I'm just really grateful for the opportunity to chat with you about

Unknown: 00:17:13

this. Not at all this is a pleasure and happy to be ahead of a longer conversation at any time. All right, we

Ashish Jha: 00:17:18

probably should find another venue to do exactly that. All right. Michael cannon, thank you from Cato Institute. Thank you so much for joining me. Thank you.

Ashish Jha: 00:17:31

All right. So there you have it. Another episode of a moment in health where we talked about one data point, 707 more than 700 rural hospitals at risk of closing, more than 300 at immediate risk of closing, with the importance of making sure that we're taking care of people in rural areas. Insurance expansion paying these hospitals adequately to make sure that these folks who live in rural America have access to healthcare. That was your data point of the week. The study of the week was about an oral GLP, one drug, or for glypron, some preliminary data, phase three study showing great benefits for diabetes control, also pretty substantial amounts of weight loss, not quite as much as we've seen with injectables, but but really still quite clinically, substantial, about seven and a half percent in the highest dose drug and reasonably well tolerated. Relatively few people got off the drug because of side effects, so I think that's promising for oral GLP ones. And then your question of the week, I talked to my friend Michael cannon at the Cato Institute, who's been writing a lot and talking a lot about his skepticism on the data on whether Medicaid expansion improves health outcomes. Now I've already talked about Medicaid expansion in this episode and other times where I believe the vast majority of the data suggests that it does improve health. Michael is a very smart guy and makes, I think, a couple of really important points. His point is, there's a lot of observational data and highest quality data. The randomized control trials have been far more circumspect in terms of their what they have shown in terms of impact. Michael's solution here is that we should, instead of just paying for a lot more of healthcare, we should demand higher quality data. I'm not going to disagree with that second part. I think we should demand higher quality data. We should work on getting higher quality data for Medicaid, for health insurance, more broadly, I

Ashish Jha: 00:19:23

guess, where I might disagree with with Mike cannon is my view is we should go ahead and expand health insurance access, while we then take the effort to to actually get better controlled data to understand what kind of impact is having on people's health. So that is an area of disagreement, but a point really worth having in our conversation, and Mike cannon is always a smart, thoughtful voice to make that point. So anyway, that's it. That's your episode of a moment in health. Thanks so much for joining me, and I will be back next week again with another episode of a moment in health. You.