Obamacare and the Mystery of Medical Science

Fools? Photo: Kevork Djansezian/Getty Images

In 2000, Margaret Talbot wrote a disconcerting story for The New York Times Magazine about the placebo effect. It remains enormous — which is to say, a huge proportion of the impact of medicine seems to be going on in our heads rather than our bodies. Medical science — as an actual science, as opposed to the “medicine” that has existed throughout most of civilization — is still a relatively young field and far more mysterious than we’d like it to be. Measuring and quantifying its impact is extremely hard.

That is what you need to keep in mind to understand how to think about the bombshell study of Medicaid in Oregon.

The explosive finding, the one that is being seized upon by conservatives, is that putting people on Medicaid did not definitively improve physical measures of their health. There were improvements, just not large enough to meet high, and arguably too-high, standards of statistical significance. Liberals are emphasizing that the study did find that being on Medicaid significantly increased both mental health and financial security, which is important. (Avoiding catastrophic costs is a major point of any insurance.) Conservatives are holding up the small, or ambiguous, measures in physical health as justification for the Republican campaign to deny Mediciad to as many people as they can.

But this still leaves open the question of how the Oregon study ought to change our thinking, and some of the barbs from the right merit serious replies. Megan McArdle, in a refreshing departure from her usual practice, has a column that is only partially infuriating, in which she argues, “Given this result, what is the likelihood that Obamacare will have a positive impact on the average health of Americans? …  however high it was yesterday, it should be somewhat lower today.” Likewise, Tyler Cowen asks, “Who is now willing to write?: 'The case for Medicaid expansion is not as strong as I had thought,' data caveats can follow after that.”

Okay: The case for Medicaid expansion is not as strong as I had thought. Now for the caveats: The case for Medicaid expansion is overwhelmingly strong. If a study found that puppies survive steep falls at a higher rate than expected, then you could say the case for throwing puppies out of skyscraper windows has marginally weakened, but would remain extremely strong. Indeed, data notwithstanding, either throwing puppies out of skyscrapers or throwing people off Medicaid are both acts of sadism.

The United States has very high levels of income inequality, a very stingy welfare state, and is the only advanced economy that does not guarantee access to medical care. The Oregon study does not raise particular questions about the efficacy of Medicaid; it raises questions about the efficacy of medical care in general. Measuring the impact of medicine is just really hard to do, yet almost nobody would volunteer to follow this frustrating fact to its logical conclusion and forgo the benefits of modern medicine.

And the Oregon study is not pushing the political debate toward a rethinking of the benefits of medicine writ large. It is only strengthening the hand of those who want to deny it to people who can’t afford health insurance. The Oregon study results from an unusual circumstance: The state had the budget to add 10,000 people to Medicaid, but far more who wanted to join, so it conducted a lottery. It is only the poor who can be subjected to Hunger Games–style experimentation with their health. In any other advanced country, in which medical care is a basic right, such an experiment would be wildly unethical.

We know that Medicaid makes people happier and less poor. We have trouble proving its impact on their physical well-being because proof of the benefits of medicine remain elusive. Unless we want to stop thinking of basic medical care as a life necessity, and we don’t, the case for Medicaid remains unimpeachable.