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Opinion: Who is selling snake oil?


In a recent The Missouri Times editorial, “Medicaid Expansion: Selling snake oil to the masses”, the author, Mr. Bearden made several assertions: 

1. Expansion would not significantly improve healthcare outcomes and would increase costs as evidenced by both the Oregon Health Insurance Experiment (OHIE) and an analysis by Ingram and Horton.

Dr. Shavonne Danner

2. Missouri departments that run Medicaid project an additional cost of $200 million per year.

3. Expansion proponents resort to “planted” articles that distract from the fact that healthcare outcomes don’t significantly improve with expansion even as cost increases.

4. Missouri should take the lead in reforming its Medicaid program by promoting alternatives, specifically mentioning Short Term Limited Duration plans.

To evaluate each of these claims I reviewed the citations provided by Mr. Bearden as well as additional and contemporary references.  To wit:

1. The OHIE is a 2008 study of individuals who received or did not receive Medicaid expansion via lottery. Mr. Bearden is only partially correct regarding outcomes. While expanding Medicaid to additional patients showed no significant improvement in blood pressure, cholesterol or glucose levels, it did raise rates of diabetes detection and management, lower rates of depression, reduced financial strain, and almost completely eliminated catastrophic out-of-pocket medical expenditures. The authors also acknowledge that the effects of expansion over time may differ from their results. Given that it may take additional time for measurable changes in health to occur, researchers suggest further work is needed to provide long term insight on self-reported health and health outcomes.

Mr. Bearden also chose to reference Ingram and Horton, two employees of The Foundation for Government Accountability, a non-profit with an emphasis on marketing and lobbying. Media notes FGA has been criticized by both conservative and liberal economists for poor data reporting. This makes their analysis suspect. 

2. Mr. Bearden did not cite his reference regarding a projected cost of $200 million per year, so I am unable to adequately evaluate this claim. I do note that E. Tsapelas with the Show-Me Institute, founded by Rex Sinquefield, recently provided testimony before the Missouri House Subcommittee on Health Care Reform. He mentions the expansion would cost $212 million in 2020 but also does not give references stating only “past estimates concluded…” Later in his testimony Mr. Tsapelas quotes the Rapid Response Review but I note that this assessment was not tasked with reviewing Medicaid expansion and possible savings/expenditures, only with looking at the current system in place. The report, therefore, did not opine on Medicaid expansion.

3. Mr. Bearden does not reference “planted” articles to emotionally sway the reader but there is voluminous supportive economic data from respected, time-honored sources such as Kaiser Family Foundation, (KFF), Robert Wood Johnson Foundation, and the Health Affairs Journal among others. KFF reports research which indicates expansion is linked to gains in coverage; improvements in access; financial security; some measures of health outcomes; and economic benefits for states and providers. In addition, a Washington University report gives estimates of the best case (+$95M) and worst case (-$42M) scenarios regarding expansion as well as noting there is a current net outflow of dollars from Missouri due to lack of expansion. In 2015 Missouri residents sent $64.1 billion to the federal government in taxes which was 1.95% of the U.S. total. We received back $6.28 billion for Medicaid which was only 1.80% of the total. This difference represents an economic loss to Missourians of $500 million each year.  

4.  Mr. Bearden gives only one example of alternative health care: Short Term Limited Duration plans. The coverage of these plans is for less than one year. The carrier can refuse the initial application due to pre-existing illness or, should an illness develop, may decline renewing the policy at the end of the term thus leaving the individual without coverage. This loss of coverage does not make people eligible for a special enrollment period to switch to an ACA plan. This may require a person to go without insurance while waiting for the next open enrollment on the ACA to apply for a plan that cannot refuse coverage due to a pre-existing condition. 

Another point:  Mr. Beardon mentions that Medicaid expansion is backed by hospitals without taxpayers’ or their elected officials’ consent. It may be true that a majority of our elected officials oppose expansion; however, it is not clear if our legislators are in step with their constituency. I urge Mr. Bearden to hold his judgment regarding the taxpayers’ will until we see if those same taxpayers put Medicaid expansion on the ballot in 2020. 

Lastly, a quick note of caution to the reader: Whether one is reading an opinion piece such as this or searching volumes of information regarding healthcare, check the references — not only for accuracy of data but accuracy of interpretation.  And beware those who present data as factual without citing a source. They might be just selling you snake oil….