Health Care | Data Science & Psychology

10Jul/11

Oregon’s Medicaid Experiment vs. Motivated Reasoning

Recently, an unprecedented study was done in Oregon where (due to budgetary, not research reasons) a lottery was held to randomly decide which applicants for Medicaid would actually receive the opportunity to receive Medicaid. There has never been an opportunity to randomly assign people to have access to a program like Medicaid, and so this represents a unique opportunity to learn something about the effects of Medicaid, especially considering the large sample size. The results were recently published and while there are multiple news reports about the article, none had the depth (or graphs) to satisfy me, hence this post as an excuse to dig deeper.

There is a psychological point to be made here too, about partisan motivated reasoning. The results of the study are intuitive to most people who are not so ideological. Of course increased access to health care leads to greater psychological and physical well-being for the insured as well as greater cost to society. I have to admit that as a liberal, I'm tempted by arguments that the benefits of preventative medicine and reduced use of expensive emergency rooms means that increased health care for the poor will be essentially cost neutral. While Obama touts improving health care access as a deficit reducing measure and liberal pundits minimize costs, the reality is likely that insuring everyone will cost significant money. At the same time, arguments that state that medicaid doesn't improve poor people's health or that minimize the effect, seem psychologically motivated as well. Indeed, the fairest summary of the results of the study would be this fairly obvious sounding ABC News headline which reads, "Medicaid makes poor healthier and states poorer". To add something to the numerous articles out there, I made the following graphs to summarize results:

People who received medicaid (in red) felt happier ("very happy" or "pretty happy" as opposed to "not too happy"), healthier, and less depressed (using this measure) than the control group (in blue).

People who received medicaid (in red) used more preventative services than control group (in blue) (yearly results for just women).

People who received medicaid (in red) used more medical services overall than control group (in blue), costing taxpayers more money, without any decrease in ER visits (yearly numbers, extrapolated from 6 month numbers in article - costs used per event in article, based on previous studies, are in parentheses).

Partisans will surely see it through partisan eyes, as one man's enormous gain in outcomes is another man's modest increase. The National Review had a fairly detailed critique, but I can't help but feel that statements like "supporters must show not only that expanding coverage improves health but also that it does so at a lower cost to taxpayers than alternative policies" ring hollow unless advocates are forcefully pushing for those policies on the grounds of improving the health of the poor. It has the same feel as liberal arguments that taxing the wealthy will actually stimulate the economy. Both groups don't like to make tradeoffs, even obvious ones, but the reality is that expanding health coverage will both cost money and improve health.

Is it an unaffordable amount of money or a trivial amount? The other neat thing about the study is that it actually translated health usage into actual dollars spent per year. The control group still spent money on health care, which was presumably taken care of through existing services, charities, or emergency rooms. The marginal cost of insuring the poor could be seen to be the difference between the experimental and control groups or the total cost of the experimental group. Under medicaid, the government would pay all those costs, but there may be savings on what government is already spending on emergency room visits to public hospitals and other like societal costs. In comparison, I found these links for the yearly cost of educating a child or incarcerating a prisoner in Oregon.

Oregon Medicaid Experiment Costs per Year in Context

Yearly Cost

Of course, the above graph is perhaps misleading as there are far more school children than prisoners, so perhaps multiplying the total cost of care by the 213,000 medicaid eligible uninsured individuals or by the almost 650,000 total uninsured (numbers from statehealthfacts.org), and comparing it to the overall Oregon budget might put the cost of expanding coverage dramatically in context. Below are yearly Oregon state budget items compared to extrapolated medicaid costs. Note that the cost of insuring all uninsured is likely lower due to many uninsured being young working adults. However, there is likely overhead and administrative costs to the program that are not taken into account as well, so perhaps this balances out.

Oregon Medicaid Experiment Costs in Budget Context

Oregon Yearly Budget Items in Comparison to Potential Expanded Health Care Cost

I learned something from this exercise. My liberal intuition was that expanding coverage to all the uninsured would not be that large a cost for a state. In reality, it looks like expanding Medicaid in Oregon would be roughly equivalent to the entire budget of the Oregon University system or at least the community college system, depending on whether you count the entire cost of medicaid health care or just the marginal cost of increased usage. Either way, it is a significant cost. At the same time, providing health coverage to all the uninsured is not fiscally impossible. It costs a fraction of the overall state budget and would cost a fraction of the Oregon health and human services budget. Behind all the reactions to such studies is the attempt by both liberals and conservatives use motivated reasoning to avoid a hard choice between a costly government program and failing to provide health care for our nation's poor. There is a cost, in terms of money or well-being, to either position.

- Ravi Iyer

Tagged as: health care, medicaid 3 Comments

23Mar/10

The Psychology of Aggression and the Ugliness of the Health Care Reform Debate

Most people are not violent people. From an evolutionary perspective, it makes very little sense for a species to kill members of it's own species. Soldiers in war have to be trained out of their natural impulse not to fire weapons. For the vast majority of people, aggression is a last resort and I'm guessing that most readers have anecdotal evidence of this as rarely do everyday disagreements escalate into physical or even direct verbal attacks. It's usually not worth the risk and stress to our systems.

There is lots of psychological research on how to reduce these inhibitions (e.g. dehumanization, Milgram's obedience studies), but there is little research (feel free to let me know if I'm wrong about this and I'll edit this) on the positive pressures towards aggression. Among the ideas I am familiar with are Sherif's classic studies on competition for limited resources, which are echoed in Robert Wrights's ideas about zero-sum competitions leading to conflict. However, competition itself is just a circumstance and it doesn't necessarily get at the psychological mechanism for group level aggression. For example, people may compete because they covet a particular resource or they may compete because they need that resource to survive.

A couple years ago, I hypothesized that individuals are moved to aggression because of an excess of moral principle, rather than the absence of moral principle. In the context of the health care reform debate, this may mean harming others "for the greater good", which could be defined as saving unborn fetuses, providing health care to the sick, defending the constitution, fighting for liberty, or an assortment of other moral principles which have been asserted by both sides as justifying actions that might normally be considered out of bounds. In the past few days, we have seen gun threats, windows broken, the elderly disrespected, and slurs and spit hurled at politicians. These incidences of crossing boundaries in the name of a cause are not limited to one party as those in favor of health care have harassed Bart Stupak and tried to have Joe Lieberman's wife fired. No side has a monopoly on the ugliness.

I don't have data that speaks directly to this question, but I do have this graph to consider. At the time that I started thinking about what I call 'hypermoralism', I created a small educational website that I thought I'd use to gather some exploratory data as I thought about these issues. The website is still in beta but the results of the initial survey are interesting. I asked people to think of a group that committed violence against civilians (e.g. 30% picked the Nazis) and think of the motivations behind that violence. I then asked people to think of reasons why, in an extreme case, they themselves might endorse violence against civilians.

Reasons to support violence against civilians

As you can see in the above graph, people believe that notorious groups that kill civilians are amoral ("They were amoral, having no moral standards." or "They were seeking personal gain at the expense of others.") most of all and were willing to entertain the idea that they were hypermoral ("They were killing people who belong to a specific group to avenge a past injustice committed by other members of that group.") as that value was still close to the midpoint of the scale. Survival ("They were killing people because they themselves would be killed if they did not.") was a distant third motivation.

In contrast, when people considered when they would potentially resort to violence against civilians, survival (of both the individual and the family, which loaded on the same factor in a factor analysis) was the prime potential motivator. Unfortunately, for my hypothesis, moral reasons were deemed no more likely than non-moral reasons for individuals, but I still think there is something to be learned.

Clearly, these scenarios are not directly comparable as the average respondent is likely actually different than the average Nazi or member of the Khmer Rouge. It's not just a matter of perception. But if we believe in the vast amount of research on the fundamental attribution error, which shows that we underestimate situational pressure when others do bad things, there likely is some amount of attribution error occurring in this instance. It seems likely that many individuals within these notorious groups actually did feel some survival motivation that spurred their actions. For example, Hitler was quite poor, though clearly his actions went way beyond mere survival.

In the health care reform debate, it seems that a precursor to the ugliness is indeed couching the debate in terms of a life or death struggle for survival, justifying questionable behavior. Is America hanging by a thread? Then I suppose it's worth taking extreme measures to save it. Are people dying every day that reform isn't enacted? Then I suppose a few harassing calls to a congressman's home are a small price to pay.

Politics in America can often be a zero-sum game and it is inevitable that passions will be inflamed on both sides. Liberals may have 'won' this vote, but we all lose when the debate gets too ugly and liberals are just as guilty of exaggeration when things don't go their way. Indeed, I just received an email asking for help to "stop big corporations from taking over our democracy", a reference to a recent Supreme Court decision which conservatives "won". Such rhetorical devices may be useful, but we should all guard against where such exaggeration inevitably leads....ugliness.