The Oregon Medicaid Experiment Good Study Bad Politics

Examining the Oregon Medicaid Study

By now, most Disease Management Care Blog readers have probably read or heard about the release of the health and costs outcomes data from the Oregon Medicaid experiment. The purpose of the study was to ascertain whether one of the arguments still being used to support the Affordable Care Act is really true, i.e. that health insurance leads to better health leads to lower health care costs.

Its not a minor argument. When the important provisions of the ACA go "live" in 2014, liberal-progressive supporters of the ACA will be tenaciously seeking to validate the merits of health care orm, while conservative critics will be looking for any excuse to strangle Obamacare in its crib.

So naturally, if a well performed study supported or contradicted the health insurance hypothesis, it would make little political difference.

How was the study done?

Unable to afford universal enrollment of approximately 30,000 eligible persons into Medicaid, Oregon figured the only fair way to administer the program was to have a lottery. Because participating individuals were allocated to one of two options (with or without Medicaid) by chance, Oregons approach had all the makings of a prospective randomized clinical trial.

The lottery was conducted in 2008 and the health status and health care costs for the winners and losers were compared using face-to-face interviews an average of 25 months later. While the lottery was state-wide, the study itself was limited to the Portland area. The researchers planned to compare the health status of 10,405 individuals who had won the lottery to 10,340 individuals who had lost and were not enrolled in Medicaid.

Not all persons signed up for Medicaid and others couldnt be tracked down for the one-on-one interviews, leaving a final number of 6487 (62% of the eligible) lottery "winners" versus 5842 (57% of the eligible) "losers."

What were the results?

All in all, the results were disappointing for persons believing the health insurance hypothesis. Having Medicaid didnt lead to better control of high blood pressure, diabetes, blood cholesterol levels or overall cardiac risk. There was also no impact on the likelihood of being admitted to a hospital or having to go to an emergency room.

The good news was that having Medicaid seemed to lessen the likelihood of battling untreated clinical depression and, if pap smears and prostate specific antigen tests are markers for access to primary care services, Medicaid increased that also. Last but not least, Medicaid participants were less likely to have catastrophic medical expenses or be in debt to cover medical bills.

Was the study perfect?

Nope. The studys generalizability was limited by being restricted to persons age 19-65 years in Medicaid and in an urban environment. Two years may not be long enough to truly gauge the benefits of having insurance. Many persons were lost to follow-up. Statistics limited the ability of the researchers to spot smaller improvements in health status.

And how did supporters and detractors of Obamacare react?

As expected. If bloggers are a window into the soul of the body politic, this KHN article amply demonstrates that no ones mind has been changed. Between inflating or minimizing the studys imperfections, cherry picking the outcomes and spinning them, we are no closer to achieving any consensus.

The Disease Management Care Blogs take:

Studies like the Oregon Medicaid study are not only rare, theyre as good as were going to get. Since no study is perfect, the likelihood that Washington DC will be able to use any nuanced research insights to inform the next steps in pursuit of the Triple Aim is not good.

The battle lines have hardened.

New study suggests using sedentary behavior counseling in primary care

Although primary care physicians take care of many aspects of health and disease, little is known about how they can change sedentary behavior through counseling, according to researchers at The University of Texas Health Science Center at Houston (UTHealth). Results from a new study suggest encouraging patients to decrease the time they spend sitting each day may be feasible in the primary care setting.

“Reducing sedentary time can be done by virtually everyone and requires smaller changes in energy expenditure than meeting physical activity guidelines, which usually entails a complex behavior change particularly for inactive patients,” said Kerem Shuval, Ph.D., principal investigator and assistant professor of epidemiology at The University of Texas School of Public Health Dallas Regional Campus, part of UTHealth. “Reducing sedentary time helps promote health and primary care physicians can play a major role in modifying their patients’ sedentary behavior, particularly because adults spend many of their waking hours each day sitting or in passive leisure activities.”

Results were recently published online in the British Journal of Sports Medicine.

Unlike physical activity counseling, which has been investigated over the years, sedentary behavior counseling is a new term used in this study to describe a dialogue with a patient about the harmful effects of prolonged uninterrupted sitting. The average amount of time spent sitting or reclining during waking hours in the United States is almost 8hours per day, according to data from the National Health and Nutrition Examination Survey.

In this study, Shuval and his colleagues asked adult primary care patients whether their providers asked, advised and encouraged them to modify their physical activity and sedentary behavior in the past year. The “5A” (ask, advise, agree, assist and arrange) framework was used to examine these questions.

Study results indicated that within the last year, only 10 percent of patients received sedentary behavior counseling compared to 53 percent who received physical activity counseling. No patients received a plan pertaining to decreasing sedentary behavior; however, 14 percent were provided with a written plan for increasing physical activity. More social support and specific strategies for behavior change were provided as it relates to increasing physical activity than decreasing sedentary behavior. Obese patients were more likely to receive counseling to decrease their sitting time.

“Accumulating evidence has found prolonged sitting to be associated with increased risk for chronic diseases such as obesity and type 2 diabetes as well as premature death,” said Shuval, who is also an adjunct professor at The University of Texas Southwestern Medical Center (UT Southwestern) and a member of the Harold C. Simmons Cancer Center at UT Southwestern.

Sedentary behavior has emerged as a new field of scientific investigation due to the detrimental health effects of prolonged sitting, according to Shuval. A number of studies have begun to explore the impact of interventions specifically focused on reducing and breaking up sedentary time.

“Our study provides initial insight into sedentary behavior counseling practices in the primary care setting,” said Shuval. “Additional research is needed prior to developing programs to change patients’ sedentary behavior.” Several countries have already begun to provide general recommendations to decrease sedentary time.