For those who are unaware, President Obama recently published an article at the Journal of the American Medical Association. If you follow academics on Twitter, you likely saw it. President Obama is the first sitting President to publish an academic journal article, which is kind of cool, but I don't want to dwell on that observation. The article is an analysis of the effectiveness of one of the President's signature policy initiative, the Affordable Care Act (generally called "Obamacare," a term I personally loathe... but that's another story) and associated healthcare expansions. It also includes further policy recommendations.
The article falls squarely into American healthcare policy, one of my areas of interest, so I wanted to offer a short summary of the major points of the article and some comments. The article is very short, only 7-pages, and it isn't paywalled. For those who are interested, I do suggest taking a look at the original.
The key points of the analysis are in the summary, but they are also well-chewed talking points you're likely to hear on the Sunday morning talk shows. (Well, you would hear them if the guests on such shows were inclined to indulge in arcane things like facts and statistics.) I present those claims in order of their credibility, and I dispense with some of the mushy, politically expedient anecdotes the President included that make the thing read less like a scholarly article and more like a policy speech.
1. The enactment of the Affordable Care Act, particularly the Medicaid expansion provision, is responsible for the largest decrease in the uninsured rate since the creation of medicare.
2. Predictions that the Affordable Care Act would have an adverse effects on employment seem not only unfounded, but outright mistaken.
3. The quality of care patients receive under the provisions of the Affordable Care Act is measurably better than what patients received, and various research initiatives put forward by the administration will improve that quality even further.
I take it that (1) is probably the most important claim in the article, and one of the most important claims in understanding the legacy of the Affordable Care Act. While the percentage of uninsured Americans had been decreasing since 2006 (it peaked at 15.8%; about 47 million Americans, according to the Census Bureau), the President's article shows a dramatic decrease of about 5 points during enacting the Affordable Care Act. This number is uncontroversial amongst reality-oriented people; the Census Bureau and the CDC have reported all-time lows of just under 10%.
For those who are skeptical of the causal responsibility of the Affordable Care Act initiative, President Obama's article provides a persuasive case (though hardly original) based on a few significant data-points. The most important is that there seems to be an enormous difference between states that adopted the Medicaid expansion provision and states that didn't. He provides the following graphic:
Now, for the skeptic, it is important to keep in mind that there are some pretty significant sociological differences between the states that are inclined to adopt Medicaid expansion (e.g. CA, CN, MA, NY, etc.) and those that aren't (e.g. FL, GA, SC, TX). See the current list of states that have adopted medicare expansion here to get the picture.
Still, that's not a particularly compelling argument against the ACA as much as an observation that states that aren't going to provide increased access to Medicaid are going to have fewer folks in their states who are insured. That seems basically tautological.
The more interesting version of the observation has been made by groups including the Kaiser Family Foundation, that about 11 million people gained access to Medicaid following the introduction of the expansion.
I am not sure how many hardline skeptics are going to be compelled by the data that the Affordable Care Act increased access to coverage; still, these statistics seem pretty hard to dispute and the dramatic swing following the introduction of Medicaid expansion seems to be largely facilitated by this work, given that the 11 million additions to Medicaid alone contribute to that reduction in the uninsured rate.
The second point is really just a jab, so far as I can tell, at those who said that increasing mandates on employers would lead to large scale layoffs and a dramatic increase in unemployment. There's not that much to say about those claims beyond the fact that unemployment has been dropping pretty steadily since 2010 (which, coincidentally, is when the Affordable Care Act was passed). There have been a number of claims about the "true unemployment rate" being far higher, but those claims are not supported by Census Bureau or Bureau of Labor Statistics data.
Now, no one should suggest that the Affordable Care Act improved unemployment numbers, though there have been jobs added in the healthcare industry over the last six years. (The health care and social assistance industry has been consistently adding jobs, including adding 58,000 jobs last month, June '16.) At the very least, this original objection to mandates on employer coverage seems not to have come true.
The third part of the article is the one that demands the most skepticism, and is not even really defended in the article. There is no information (so far as I can tell) that suggests qualitative healthcare outcomes have improved since the implementation of the Affordable Care Act. The Department of Health and Human Services differentiates qualitative metrics for healthcare, and while one of those metrics (namely access) has decidedly improved under the ACA, for all of the reasons sketched above, the other metrics have not followed.
It is hard to map things like patient outcomes over short periods of time, because the impact of access to healthcare in 2010 may not have a clear beneficial outcome for a patient until 2020 or 2030; this is especially true when it comes to talking about young people, who were one of the major targeted demographics in the ACA reform. It just isn't feasible to make a judgment about whether the quality of American healthcare has improved. In 15 or 20 years, when we have data done on these long term metrics, like patient outcomes in life expectancy and quality of life, we can make that judgment.
During the last few months, the President's administration has talked about the expansion of medical research in pursuit of treatments for, in particular, cancer. The goal is to improve patient outcomes through an increase in research spending, and the President acknowledges this effort in his article. This project, the "Moonshot" as they're pitching it, is not particularly well founded. Oncologist and (dare I label him as such?) sociologist of medicine Vinay Prasad has an op-ed on the scientific skepticism, there have been renewed discussions about if and how to share data, and (most cynically) it seems like a political stunt preying on the hope and naivety of those who don't understand how scientific research actually progresses. The increases in spending associated with the initiative are probably going to be good for a lot of cancer researchers, but (at a minimum) have blown expectations way out of proportion.
I'm reminded of an episode of the West Wing where President Bartlett overhears some oncologists talking about prospective treatments for cancer, and decides to announce in the State of the Union that they're going to cure cancer in a decade. (I wonder what White House aid was watching that episode, aired in 2002, and thought, "Hey, we should actually do that.")
I should say, there is no evidence that healthcare outcomes have gotten worse, and very little reason to suppose that initiatives like Moonshot will do any damage to medical research. (There are issues with apportionment and opportunity costs, but those are more technical worries than just the worry of, to quote a great philosopher, "mo' money, mo' problems.")
At best, though, there isn't adequate evidence that there have been significant improvement in patient outcomes as a result of changes in the Affordable Care Act. Those qualitative outcomes, while we might be cautiously optimistic and work hard to improve them, are something that has to be assessed more in the long term. For those who are interested in the studies on the ACA, though, President Obama's article does act as a good study of the improvements in coverage brought about by the marketplaces and Medicaid expansion, and shows that the legislation has accomplished several of its most important goals in increasing access to healthcare and decreasing the number of individuals without insurance.
Joshua Stein is a guest blogger at Neuroethics and Law. He has studied at the graduate level at New York University and is starting in the fall as a doctoral student at the University of Calgary.