Tuesday, January 17, 2017

Healthcare Policy Changing. Falsifiable Predictions Wanted.

When the ACA first passed, I remember posing the following challenge: “Ok, ACA supporters, you got your law. Now what’s going to happen? How will the benefits manifest themselves? Make a prediction that we can check. In a few years you should recant if you’re way off. I may take a bet against your prediction, if it’s well-specified enough.”

It would have been interesting to hear people’s actual responses to my question, assuming anyone had thought about it. I was fishing for something like, “Mortality rates will fall for poor minorities by X deaths per 100k population,” or “Diabetes rates will decline by Y%, high blood pressure by Z%, among the currently uninsured population.” The point here is that a healthcare law should somehow affect health, and if it doesn’t noticeably do so it has failed as public policy. It’s fake medicine. The people who were singing the praises of Obamacare should have been willing to make some kind of falsifiable prediction the moment it passed. I took their unwillingness to do so to imply a lack of serious thinking. I never got a meaningful response, nor did I see any prominent pundits or bloggers independently come up with the same idea.

(By the way, it’s not enough for someone to point out that an improving trend has been at work since the law was passed. It could be a pre-existing trend that can’t possibly be attributed to the law. In fact, life expectancy has risen since 2000 so you have to be really careful about attributing any improvements in health to a bill passed in 2010. One has to show that any pre-existing trend has improved above and beyond the trend-line.)

One might have answered something like, “The world is really complicated, and a lot of things affect the overall health of any population. I’m unwilling to make such a prediction.” This would have been an interesting admission. If the major supporters of the ACA thought that the benefits are too small to measure, or so small they would be swamped by noise, they should have at least said so. Some of us think it's unwise to waste massive resources in pursuit of benefits that are speculative or invisible. 

One might have given another sort of answer, something like, “The law would work if implemented, but stupid Republican states will fail to implement it and stupid Republicans in a future Congress will hamstring the law.” I can imagine someone being tempted to issue this hedge, but again this is something that needs to be stated ahead of time. The person giving this kind of answer is predicting failure, and failure based on something endogenous to the system. If the failure of public policy is that predictable, we should oppose such policy. Your political initiative might have worked if it weren’t for that incorrigible opposition party, just as your lunar program might have worked were it not for stupid gravity!

Today it looks like some kind of repeal is imminent, and doomsayers are predicting some kind of blood-bath as people lose their insurance coverage. I seriously doubt it, but I am willing to hear from anyone capable of discussing this at room temperature. What *precisely* do you think will happen?

My own view is that health policy doesn’t matter all that much in terms of getting actual health outcomes, although bad policy can certainly be very expensive and saddle us with enormous burdens. The social science is pretty clear on this point. An individual’s “insured status” has little correlation with health after you’ve made the appropriate demographic adjustments; it simply isn’t true that insuring someone grants them “access to healthcare” in a way that makes them healthier. (Or more precisely, a population of such people won’t get healthier; any one such someone might get healthier or sicker. But it’s the population effect, not some individual’s health outcome, that tells you something about causation.) I have a long reading list for anyone who doubts this. Start with Cut Medicine In Half by Robin Hanson, and do go on to read the entire discussion. (Cato Unbound, where the essay was hosted, is a forum. In this particular one there are three other health policy experts who, while they never actually say Hanson is wrong, take issue with his claims.) Read In Excellent Health by Scott Atlas; here is a podcast of him discussing the book on Econtalk. Also check out Overtreated by Shannon Brownlee, Catastrophic Care by David Goldhill, Crisis of Abundance by Arnold Kling, Affordable Excellence: The Singapore Healthcare Story by William A Haseltine, Priceless by John Goodman, and I’m sure I’m forgetting a few others. Also listen to any episode of Russ Robert’s Econtalk that talks about healthcare, especially anything with Arnold Kling or Robin Hanson. Most people balk at the claim that people don’t get healthier when you give them a bunch of free medicine, but I’m on very solid ground here. Go review the literature a little if you're skeptical. I'll wait. Given all this, the obsessive fixation on getting healthcare to “the poor” is misguided. This is mostly not a fight about access to healthcare, but rather about who pays for what and how. 

My own prediction would be something like: Policy tweaks of the "pass/repeal the ACA" kind won't noticeably affect health outcomes (although much larger restructurings might). Policy tweaks that cause patients to face a larger proportion of the bill would result in cost savings with no measurable effect on health outcomes. I could try to be more specific if a specific proposal is on the table. But the people who are predicting disaster from the repeal of a seven-year-old healthcare bill look positively daffy. In terms of evidence-based policy, they don't have a leg to stand on. 

No comments:

Post a Comment