Oregon study a wake-up call
Medicaid needs to change as it expands to improve outcomes
Recent findings from the Oregon Health Study have resulted in headlines intended as a warning for next January’s planned expansion of the Medicaid program (as part of the Patient Protection and Affordable Care Act):
“Bad news for Obamacare: A new study suggests universal healthcare makes people happier but not healthier”
“Oregon study throws a stop sign in front of Obamacare’s Medicaid expansion”
“Giving people government health insurance may not make them any healthier”
Overall, the theme of these articles and much other commentary has been that, given the study’s lackluster results, the Medicaid expansion, which will cost billions of dollars, should not go forward. The headlines have missed the point.
The Oregon Health Study refers to a 2008 initiative that expanded Oregon’s Medicaid program to 10,000 low-income individuals who were chosen through a lottery. The findings, at best, were mixed, with a decrease in rates of depression and reduced out-of-pocket expenses, but no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions; no improvement in individuals’ diabetes; and an increased use of many preventive services and doctors’ services.
Let’s reframe the discussion. First, the Affordable Care Act, like the Oregon lottery expansion, is primarily intended to increase access to healthcare services by eliminating financial barriers. The Oregon project accomplished this. And this is one of the key goals of the pending Medicaid expansion.
Second, the implications of the findings are subject to significant debate. Some have seen the results as a warning that the ACA expansion may not lead to health improvement, while others question the methodology but acknowledge that it was disappointing that the findings in some cases did not significantly improve health outcomes.
Here is what is key: Regardless of how the
If the Medicaid program just expands but does not change, we will not achieve significant improvement in participants’ health statuses.
results are interpreted, the study does provide a wake-up call. Next January, the Medicaid program will expand. If the program just expands but does not change, we will not achieve significant improvements in participants’ health statuses.
The reasons for this have been well-documented. Our current healthcare system does not work: It is fragmented; healthcare is not coordinated; services are provided and, most often, paid for in an old-fashioned piecemeal way with no accountability for outcomes; and in many cases, poor care is rewarded with additional reimbursement.
We should not be willing to accept this. Health systems across the country, including Kaiser Permanente, Intermountain, Denver Health, Virginia Mason and many others, have shown that through redesigning how they provide care in the acute-hospital and ambulatory settings, patients’ health outcomes have improved significantly.
At Geisinger Health System, this has been our mission as well. We have seen significant outcome differences for our patients both initially as well as long term after re-engineering hospital-based and primary care. One example is in Type 2 diabetes, where we fundamentally changed how we provide and pay for care and consequently achieved major reductions in heart attacks, stroke and retinopathy in our patients. We are now working with systems in several states to help them adopt the innovations we have implemented at Geisinger.
We know from our work and that of leading health systems around the country that if we want the health outcomes for the expanded Medicaid population to be different from the results now being reported for the Oregon study, patients will need to be cared for in a radically redesigned system. One push for this redesign could come from new efforts from the Center for Medicaid and Medicare Innovation, which was given, under the Affordable Care Act, the flexibility, financing and authority to function as a national change agent.
The real force for change, however, will have to come from the healthcare system itself—from health leaders across the country who will need to commit to re-engineer how they provide care and be willing to be accountable for patient outcomes. Scaling and generalizing the innovations that have already proven successful could provide a jump-start on fixing our health system in time to care for this new patient population.
Shirley Krueger of Salem, Ore., participated in the lottery for the 2008 Oregon Health Study, an initiative that expanded Oregon’s Medicaid program to 10,000 low-income individuals.