Alabama is still poised to unleash the Death Angel. The night after we wrote that post I suffered a tragic loss. Danielle Juzan, my wife and silent collaborator of 33 years was stricken and died of a heart attack at the age of 55. As you can see from the attached article, she was a wonderful, passionate woman who pushed me to stand up and do the right thing regardless of the personal or professional consequences. She was also a marvelous writer and those who have read this blog over the years will never know how much she added to these posts.
She was a fixture in the local community and fought hard for improvements to Mobile, Alabama. Her attachment to our community was what made this work so important. Over the years I have looked at several jobs in places that are better positioned to provide healthcare for all citizens. Each time Danielle would give me the reasons not to leave our house (we just got the garden where it needed to be, we are getting a dog park, etc) and ask me if we couldn’t stay in Mobile a while longer. I would agree that we had a nice life despite the seeming callousness of the public officials and we would go back to tilting at the windmill that is improving the care of the underserved in Alabama.
As I grieve, I continue to check my e-mail and am thankful for the hundreds of expressions of sympathy that I have received. For those of you who read this, thank you so much. While nothing will make it better, it is comforting to know that Danielle has touched so many.
Immediately after her death we were challenged in a message as to accuracy of the position that Medicaid (not the expansion, access to Medicaid at all) saves lives. The commenter suggested that the evidence for improved health was wanting. He pointed out that before the passage of the ACA, Oregon randomly gave several thousand people who were uninsured Medicaid coverage and followed them and several thousand uninsured for a couple of years to see what would happen. The results were as follows:
Medicaid coverage resulted in significantly more outpatient visits, hospitalizations, prescription medications, and emergency department visits. Coverage significantly lowered medical debt, and virtually eliminated the likelihood of having a catastrophic medical expenditure. Medicaid substantially reduced the prevalence of depression, but had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk. Medicaid coverage also had no statistically significant effect on employment status or earnings.
The science is pretty clear, access to health insurance over a two year period for relatively healthy people improved some aspects of their lives but is no panacea. How these findings are interpreted depends on if you live in a red state or a blue state:
A great deal of controversy exists about reducing the number of uninsured people in the United States through Medicaid expansion. Advocates for Medicaid point to evidence showing that Medicaid has been an essential part of the nation’s safety net, providing access to comprehensive health care for the nation’s most vulnerable.
Critics of Medicaid, on the other hand, believe Medicaid has put a tremendous strain on state budgets and increased dependency on government programs. They argue for state-based solutions that place more emphasis on subsidizing enrollment in private insurance for the low-income uninsured. The findings from the Oregon Health Insurance Experiment are cited by both sides as evidence in support of their positions.
Oregon did not take away coverage from required populations. This was coverage provided to folks who would not have been Medicaid eligible otherwise. Alabama is poised to take coverage away from patients on dialysis, patients with complex seizures, and premature infants. It will be a different experiment.
Kaiser has synthesized the evidence on Medicaid’s contribution to the health of the population and it is as follows:
- Consistently, research indicates that people with Medicaid coverage fare much better than their uninsured counterparts on diverse measures of access to care, utilization, and unmet need.
- Children with Medicaid and privately insured children compare quite closely in their access to and use of preventive and primary care. The uninsured do not have access to such care due to expense
- As distinct from access to primary care, access to specialty care has emerged in some research as a weakness in Medicaid relative to private insurance.
- Compared with both privately insured people and the uninsured, Medicaid beneficiaries have much higher rates of ED use. However, a substantial body of research investigating this disparity more closely indicates that poorer health and access challenges in Medicaid both play important roles in explaining Medicaid’s higher ED visit rates.
- Research investigating the quality of care received by Medicaid beneficiaries is limited, but two new analyses, one focused on health center care and the other on hospital care, indicate that the care received by people with Medicaid coverage tracks closely with benchmarks for high quality.
- One study found statistically significant but small differences at the national level between the shares of Medicaid and privately insured adults who received perfect hospital care which was more related to regional differences.
Their conclusion is as follows:
In its totality, the research on Medicaid shows that the Medicaid program, while not perfect, is highly effective. A large body of studies over several decades provides consistent, strong evidence that Medicaid coverage lowers financial barriers to access for low-income uninsured people and increases their likelihood of having a usual source of care, translating into increased use of preventive, primary, and other care, and improvement in some measures of health. Furthermore, despite the poorer health and the socioeconomic disadvantages of the low-income population it serves, Medicaid has been shown to meet demanding benchmarks on important measures of access, utilization, and quality of care.
For you, Danielle. Continue to help me keep fighting the good fight.