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The misguided intent of Obamacare                                                                                     Print this essay

Posted at: Dec/05/2013 : Posted by: mel

Related Category: Healthcare, People, Perspectives, Society, Watching America,

In case you have not noticed, healthcare has been a dominant theme in our news for most of the past three years (2011-2013). President Obama’s signature legislation of 2010, the Affordable Care Act (ACA), (aka, Obamacare) has dominated the national debate and domestic agenda. I am concerned that leveraging the web for ACA registration actually makes it inaccessible for many Americans who do not have insurance and would be the primary target audience. Also, there are significant questions about whether the back end data being supplied to the insurance industry is complete and accurate regardless of how well the web front end works. Fundamentally, the biggest concern that I have about Obamacare is if this elaborate, complex and costly plan will make us healthier?

I am aware that the intent of the ACA is to get more people seeing doctors on a preventative basis. Additionally, getting people needed prescriptions and critical hospital care access at an affordable level that minimizes the risk of personal bankruptcy is a valued notion. Nevertheless, does this access to care make us healthier, or make our lack of healthcare more tolerable?

We all know that person who has lived a robust and healthy life. I have a friend who is 5-10 years my senior, he drinks milk every day, is skinnier in the middle than most adults half his age and has virtually never seen a doctor or taken a medication in his life. Being a tradesman with his own small business, he opted to go several years without health insurance for himself. Eventually, when my friend turned 65 he signed up for Medicare. Since signing up for Medicare he has stopped drinking milk, drinks alcohol periodically, wears larger pants and by most standards would be considered unhealthier than before. If you are a radio “shock jock” or a naively informed politician you would argue that “the insurance made this man unhealthy.” A simplistic view of the data does support this notion, but I am not so myopic in my world view.

Instead, what I believe my friend experienced is a concept known as the moral hazard. Two economists wrote about this exact scenario in a 2006 research article. (National Bureau of Economic Research, www.nber.org/papers/w12764.pdf ). What the economic researchers found was that many men, at the time they obtained Medicare, started behaving badly. Moral or morale hazard is a term largely used by economists to describe the actions of people more willing to take risks such as eat fatty food or driving fast cars because they feel they are insulated from the worst case cost or outcome of their actions. In this case, because the men in the study got Medicare insurance, they appeared to feel insulated from the risks associated with making unhealthy choices.

The men in the study group, once enrolled in Medicare clearly took worse care of themselves and actually exercised less. Among those who didn't visit the doctor after getting insurance, the effect was dramatic: Their overall physical activity dropped by 40%; they were 16% more likely to smoke cigarettes and 32% more likely to drink alcohol.

Even if this data seems extreme, it's still raises a worthy question: Does health insurance make us healthier?

When Health and Human Services Secretary Kathleen Sebelius at the end of October 2013 was asked this exact question, she downplayed the concerns and quickly started sharing her certainty that the infamous healthcare.gov website would be up and running by the end of November. My father once told me in a cynical moment that “politicians and their cronies are like magicians, they specialize in misdirection and illusion.”

There will come a time when the healthcare website is working as planned. In this same future, the insurance industry will be rapidly ingesting the supplied data and providing medical insurance to more Americans. The list of available doctors within a reasonable driving distance may shrink; our tax bills, wrapped in a lot of double speak will likely go up. Nevertheless, we will eventually succeed in expanding the number of Americans who have medical coverage, but if our goal is to be healthier, I doubt we will have made any improvement.

Access to insurance does not create health and a remarkable study published in the spring of 2013 in the New England Journal of Medicine supports this. (www.nejm.org/doi/full/10.1056/NEJMsa1212321) The report focuses on data garnered in an important experiment known as “The Oregon Experiment.” Faced with budget challenges, the State of Oregon decided to conduct a random lottery to allocate roughly 12,000 expansion slots in their Medicaid program. While this implementation was controversial, it was also a goldmine for researchers. Most statistical studies require some type of “blind” group or data set to validate the study data. In the Oregon Experiment, researchers had the unique opportunity to compare the newly insured to their highly similar counterparts, who remained uninsured. The results were surprising, and mostly disappointing.

The newly insured Medicaid population of Oregon did go to the doctor more often, used more preventive health services and received more medications. Problem was, in nearly every contemporary benchmark, they weren't any healthier. The scientists interviewed more than 12,000 people and compared some of the most important health indicators. They found having insurance did not improve measures of cholesterol, blood pressure, BMI numbers or how well diabetics managed their blood sugar. The 10-year risk indicators for having a heart attack didn't change in those who had Medicaid. If access to health insurance is supposed to make a person healthier, this unique study debunked that idea.

There seems to be a metaphor here for other aspects of life. When I first got married years ago, a friend said that “marriage is good for your health.” More than 25 years of marriage has taught me that being married all by itself isn't necessarily good or bad for your health. It was the effort required to make it a good or bad marriage that has driven it to achieve one category or the other. Short answer: Marriage is good for your health…as long as it’s a good marriage.

Clearly, whether talking marriage or health insurance, there are potential “good” and “bad” outcomes depending on the level of personal responsibility and accountability that you are held to.

Medical insurance has plenty to offer. A major Institute of Medicine report in 2009 found that uninsured adults are more likely to die from cancer or not recover from a serious injury. In the Oregon Experiment, the newly insured were 30% less likely to suffer from depression and none of the insured faced a catastrophic medical expense. It could also be that the lack of financial risk directly impacted the incidence of depression?

It seems that the choices we make in our daily lives have more to do with our overall health than our insurance. Researchers in another study estimated that if all Americans exercised 30 minutes a day, we would reduce the number of heart attacks and strokes by a third! That means that just using the stairs, parking at the far end in the store lot and walking the dog every day can have a serious impact on creating a healthy America. According to the Centers for Disease Control and Prevention, you don’t need to knock yourself out, three 10-minute walking sessions each day where you work hard enough that your breathing is slightly labored achieves the same value.

Our President clearly values the health care system in France which in 2000 was ranked as being the best in the world by the World Health Organization. Yet, there's a huge difference between the United States and France that has little to do with the health care safety net. Americans are three times as likely to be obese as the average French person -- and obesity is related to just about every chronic disease imaginable.

I have personally failed at this challenge. Until a decade ago, I worked hard to break a sweat every day. Now I make work and lifestyle excuses for not having the time and it shows in the size of my pants.

I’ve been fortunate to have health insurance most of my life. Recently I started revisiting my choices in activity to start losing weight in order to avoid the seemingly inevitable diagnosis of heart disease or diabetes. It has not been hard and it did not require using my insurance, it has required me making choices every day to walk more and not be consumed by work and pressures applied by others as much.

There is lots of good advice about eating more vegetables, drinking more water, etc…We don’t have to stop eating or go to a doctor to become healthier, we do have to get up and move more.

The basic concept of making quality medical care accessible to more Americans without the risk of excessive personal financial strain is noble. Despite all the rhetoric, Obamacare will not make us a healthier country. We have throughout our history adopted all the latest innovations which by their nature replace manual effort and physical activity with greater productivity. It might be time for us to reverse that approach and put more old fashioned sweat back into our day if we really want to be healthier. Having healthcare insurance is a nice, but being healthier and learning to make healthier choices should be the real goal.

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James Baldwin
Not everything that is faced can be changed. But nothing can be changed until it is faced.
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