We don't know whether Obamacare was a net gain

(Bloomberg View) — Last week was a wild adventure on the health care front, as the House seemed to inch closer to passing a bill that repealed or altered significant chunks of the Affordable Care Act —Obamacare —  before shying away at the last minute. With Democrats proudly declaring that they saved millions of Americans from the brink of disaster, it seems an appropriate time to consider the latest assessment of what Obamacare has actually done for those people.

Related: Feds see Medicaid enrollees getting appointments faster

There’s a new paper out looking at how the ACA has transformed health care access, and in turn, what that has done for health. The authors’ first answer probably won’t surprise you: When millions more people became insured, more got checkups and primary care doctors. But it’s not obvious that these people got any healthier. As the paper puts it: “No statistically significant effects on risky behaviors or self-assessed health emerge for the full sample.”

Other studies have found substantial effects on self-assessed health, but on the harder markers of health — like blood sugar, cholesterol and blood pressure — the famous Oregon Medicaid Study found no significant improvement when government gave people health care.

It turns out the link between “health care” and “health” is not as close as we would like. Health insurance is not magic. Insurance can give you access to a doctor, but it cannot make you take your medicine. An absolutely astonishing percentage of people don’t take their hypertension medication, even though the side effects are minimal, the medications are cheap generics, and the benefits are large; overall, about 50 percent of patients seem to fail to take their medicine as recommended.

Insurance cannot make you stop drinking or smoking or overeating. Just ask the primary-care physicians charged with bullying people out of those behaviors. Yes, people with health insurance are more likely to be healthy. But people with good health insurance are also more likely to be successful folks who are remuneratively employed, which seems to be independently correlated with health, even when everyone is getting their health care through Britain’s National Health Service.

Separating the effects of one health factor from another can take decades. (Photo: Allison Bell/LHP)

Insurance v. economics v. habits

Even as some people use health insurance to get their blood pressure down or their lung disease treated, others will fail to comply with treatment regimens, or will get treatments that turn out in hindsight to have been a bad idea, or will spend money on unhealthy things now that they’re spending less on health care. Which effect ends up being larger in aggregate is an empirical question, even though individuals may be able to point to a very clear benefit or detriment to themselves.

That empirical answer ends up being … kind of cloudy. Some studies show large health benefits from health insurance, others little, none, or even negative effects.