Whether the Patient Protection and Affordable Care Act (PPACA) coverage expansion and commercial health insurance provisions are morally justifiable is a big question for free-market purists.
For many other people, a much bigger question is simply whether any of the provisions will really work, and, if so, which ones, how well, and over what kind of timeframe.
A cost control provision might work great in the first few years, for example, and then cut down on doctor, hospital, agent or carrier competition, and backfire in later years.
A vaccination benefits mandate might increase costs in the early years and lead to huge savings in later years, by preventing and postponing illness.
An effort to limit the value of group health benefits (example: the PPACA Cadillac plan excise tax) might encourage insurers to carve out some services and let consumers pay for those through separate insurance policies or prepaid benefits programs.
But, of course, conventional wisdom might be wrong. A cost control program that wipes out competition might permanently lower costs. The cost of a vaccination mandate program might always outweigh the benefits. A Cadillac plan tax could scare everyone into accepting skimpier benefits packages. You never know. In health finance, experiments are a lot better than theories.
One great thing the PPACA Medicaid expansion and PPACA public exchange subsidy programs could do, even if they eventually fail in every other respect, is simply give analysts better data on what happens when various types of people get various types of insurance.
Does having any kind of coverage help those people get better care? How much does getting care actually improve their health, their years of a healthy life, or their overall lifespan?
What kinds of care improve the newly insured people’s outcomes?
What kinds of care, if any, seem to do the most to control the cost of care?
Managers of all existing and future health care access programs could use the data to improve the programs.
At this point, even giant health insurance companies seem to have trouble collecting and analyzing the data they desperately need to keep their operations profitable.
When Health Affairs, the academic journal for PPACA news binge readers, ran an article in the December issue about how the level of competition in the exchanges seems fine this year, I was all about to get angry about the researchers making unrealistically rosy predictions about future exchange plan competition, but then I saw that the authors included plenty of realistic disclaimers about how something could go wrong in the future.
Then I got excited about the study by Fred Hellinger showing how hospitalized patients with HIV, who were uninsured, were 40 percent more likely to die during their hospital stays than comparable insured patients, and that the percentage of hospitalizations of uninsured people with HIV in four states that took PPACA Medicaid expansion money fell to 5.5 percent in early 2014, from 13.7 percent in 2012, the first year of his study period. The percentage of hospitalizations of uninsured people with HIV in two states that rejected PPACA Medicaid expansion money, Georgia and Virginia, increased to 15.7 percent, from 14.5 percent.
The implication is that the increase in access to insurance should cut the percentage of hospitalized people with HIV who die while hospitalized.
On the one hand, it seems reasonable to think that having health insurance could help lead to dramatic improvements in care for people with HIV.
On the other hand, the number of people who die while hospitalized with HIV is not very high during any given hospitalization, and the researcher’s results table seems to show that the gap between the likelihood that people with HIV and Medicaid would die and the likelihood that commercially insured people with HIV increased every year from 2012 through 2014.
The gap between the death rate for uninsured people hospitalized with HIV and commercially insured people hospitalized with HIV stayed about the same during the study period.
It seems reasonable to think that the people with HIV and Medicaid had a tougher time in 2014 because Medicaid expansion got some very sick people covered, not because Medicaid expansion coverage killed them, but the study doesn’t really seem to provide the kind of data that would show whether PPACA had really had any major effect on the death rates of people hospitalized with HIV.
So, the study is interesting, but it doesn’t seem to be all that useful as an early indicator for what PPACA expansion is actually doing to actual care outcomes.
On the third hand, at least the study doesn’t involve any efforts to trash the legacy of George Lucas’s vision of Star Wars. So, it’s a lot better than some other eagerly anticipated media products coming out this month.