Amy Goldstein September
30, 2019 at 6:00 a.m. CDT
DETROIT — Poor people
in Michigan with asthma and diabetes were admitted to hospitals less often
after they joined Medicaid under the Affordable Care Act. More than 25,000 Ohio
smokers got help through the state’s Medicaid expansion that led them to quit.
And around the country, patients with advanced kidney disease who went on
dialysis were more likely to be alive a year later if they lived in a Medicaid-expansion
state.
Such findings are
part of an emerging mosaic of evidence that, nearly a decade after it became
one of the most polarizing health-care laws in U.S. history, the ACA is making
some Americans healthier — and less likely to die.
The evidence is
accumulating just as the ACA’s future is, once again, being cast into doubt.
The most immediate threat arises from a federal lawsuit, brought by a group of
Republican state attorneys general, that challenges the law’s
constitutionality. A trial court judge in Texas ruled late last year that the entire law is invalid, and an opinion on
the case is expected at any time from the U.S. Court of Appeals for the 5th
Circuit. The case could well put the ACA before the Supreme Court for a third
time.
President Trump has
dismantled as much of the law as his administration can, by expanding the
availability of skimpy, inexpensive health plans that skirt ACA rules, for
example, and slashing federal aid to help people sign up for coverage through
ACA insurance marketplaces.
And some 2020
Democratic presidential candidates contend the country needs further-reaching health
reforms than the ACA’s, calling for a government-financed system they call
Medicare-for-all.
The ACA’s supporters
have not taken political advantage of the signs that the law is translating
into better health — at least, not yet.
When the sprawling 2010
statute was new, a central question was whether it would help more people gain
affordable health coverage, as intended.
With about 20 million
Americans now covered through private health plans under the ACA’s insurance
marketplaces or Medicaid expansions, researchers have been focusing on a
question that was not an explicit goal of the law: whether anyone is healthier
as a result.
It is difficult to
prove conclusively that the law has made a difference in people’s health, but
strong evidence has emerged in the past few years. Compared with similar people
who have stable coverage through their jobs, previously uninsured people who
bought ACA health plans with federal subsidies had a big jump in detection of
high blood pressure and in the number of prescriptions they had filled,
according to a 2018 study in the journal Health Affairs.
And after the law
allowed young adults to stay longer on their parents’ insurance policies, fewer
19- to 25-year-olds with asthma failed to see a doctor because it cost too
much, according to an analysis of survey results published
earlier this year by researchers at the Centers for Disease Control and
Prevention.
Most of the emerging
evidence concentrates on the health effects of joining Medicaid under the law’s
expansion of the safety-net program. Medicaid is an appealing research focus
because a 2012 Supreme Court decision gave each state the option to widen
eligibility to people who are somewhat less poor, allowing comparisons between
the three dozen states that have expanded and the rest that have not. In
addition, low-income people without insurance are most likely to have built-up
medical problems that get treated once they get covered.
Michigan has emerged
as a hub for understanding the ACA’s effects on health because University of
Michigan researchers have been rigorously evaluating the Healthy Michigan Plan,
as the state calls its Medicaid expansion covering about 650,000 people.
One 2017 study compared heart surgery
patients in Michigan and Virginia, which had not yet expanded Medicaid at the
time. It found that those who had cardiac bypasses or valve operations in Michigan
had fewer complications afterward than similar people in Virginia, where more
were uninsured.
One in three Michigan
women said that, after joining Medicaid, they could more easily get birth
control. And four in 10 people in Healthy Michigan with a chronic health
condition — such as high blood pressure, a mood disorder or chronic lung
disease — learned of it only after getting the coverage, according to survey results published last month.
In a few
neighborhoods here in Detroit, the consequences for patients and their doctors
are clear.
*****
Bonnie Sparks,
dripping sweat in a mint-green T-shirt, reached the finish line of the CHASS
community health center’s 5K run/walk. As she trudged the final steps, the
center’s chief medical officer, Richard Bryce, urged workers and some medical
students to walk alongside her in the 97-degree heat, chanting her name. Then,
Bryce wrapped Sparks in a hug.
Sparks came in last
of the event’s 270 runners and walkers in late July in a southwest Detroit
neighborhood pocked with vacant lots. She was halfway to Clark Park when the
center’s executive director found her at the back of the pack and offered a
ride. “No way,” Sparks said, insisting on continuing under her own power.
The miracle was that,
at 47, she walked the course at all.
CHASS has been a
medical haven in Detroit’s Mexicantown for a half-century, since the city’s
riots prompted hospitals to close and physicians to move to the suburbs. Five
years ago, when Bryce, a family physician, arrived and took over Sparks’s care,
she weighed more than 300 pounds and could not get from the clinic parking lot
to the front door without help. She’d had her first heart attack at 34. Her
anxiety was so sharp she often could not leave her apartment.
On a rare family road
trip — to Daytona Beach — she waded into Florida waters where flesh-eating
bacteria infected an open sore on her right leg. Back home, she landed in a
hospital for 3½ weeks.
For 13 years, Sparks
had worked for a defense contractor, NCI Information Systems, overseeing two
computer help desks. But when the company lost a contract, her job ended in
late 2010, and her good HMO insurance disappeared.
Living on
unemployment, she kept taking pills for her diabetes and high blood pressure
because she could get the prescriptions for $4 a month through a Walmart
discount. But she did not have the $300 a month to pay for Plavix — a blood
thinner she needed because of a stent put in her heart — so she stopped.
“I talked to my
doctor at the time. I said, ‘I can’t afford this,’ ” recalls Sparks. “He
said, ‘You could have another heart attack.’
“And I did.”
The second heart
attack, in early 2012, was serious. Afterward, her doctors told her she should
not work. She applied for Medicaid twice and received form letters telling her
she was denied because she was not under 21, pregnant, blind or taking care of
a child.
The following year,
she appealed in writing, then asked for a hearing, but a state administrative
law judge concluded that, though Sparks had a solid job history and significant
medical problems that made it difficult for her to work, she was not
technically disabled, so did not qualify for insurance.
“I felt abandoned,”
Sparks recalls. “I nearly died. I kept thinking, ‘I am just sick right
now.’ ”
So Sparks was
uninsured when her boyfriend rushed her to an emergency room for a second time
within days after the Florida trip. This time, she was diagnosed with the
flesh-eating necrotizing fasciitis. She was having breathing distress and
kidney failure because of the infection and was placed in a medically induced
coma for most of her time in the Henry Ford Hospital.
But the day she was
admitted, April 3, 2014, was the third day the state had begun accepting
applications for the Healthy Michigan Plan. On April 29, Sparks got a letter.
She was insured.
Medicaid paid her
$132,000 hospital bill.
Since then, social
workers and a psychologist have helped ease her out of her smoking habit and
her anxiety. She met with a bariatric surgeon to consider a gastric bypass but,
by that point, had started to lose so much weight by improving her diet and
walking that she decided she did not need the surgery. By August, she was down
to 234 pounds.
Sparks has an
endocrinologist for her diabetes. A cardiologist approved a catheterization
when she had more chest pains — and inserted additional stents. And she has an
OB/GYN who treated her worsening fibroids and, when they got too severe, made
sure she got a hysterectomy.
Bryce, who arrived at
CHASS at about the time of Sparks’s infection, says she was like many sick and
uninsured patients who can get primary care through the health center but have
trouble finding medical specialists willing to treat them.
If not for the health
plan she has through Healthy Michigan and Medicare, which she has had since the
state eventually classified her as disabled, Sparks said, “I would be dead, or
I would be financially ruined.”
On the east side of
Detroit, the part of town where poverty and illness are most common and life
expectancy is shortest, Healthy Michigan has transformed the lives of patients
at the Mercy Primary Care Center. Like Sparks, David Brown says that, without
it, “I probably would not be here. I would have had a heart attack and died.”
Before Medicaid
expanded, all of Mercy’s patients were uninsured. Now, at 55, Brown is among
the half at the clinic covered by Healthy Michigan.
Right after he got
laid off in 2007 from a job with Wayne County, driving trucks and front-end
loaders at the airport, he began having spells in which his chest was tight,
his head spinning. Finally, a friend took him to an emergency room. He was
prescribed rest and ordered to follow up with his primary care doctor. Except
he did not have one.
Over the next few
years, the spells came more often, and he was going to emergency rooms around
town, dizzy and with headaches, two or three times a month. When the bills
showed up, he stored them, unpaid, in the brown plastic crates where he keeps
files.
He does not remember
anyone checking his blood sugar, even though his favorite foods were fried
chicken, Burger King, cinnamon doughnuts, chocolate milk and — especially —
Snickers bars.
Finally, during an
emergency room visit, someone mentioned he might be borderline diabetic.
When he finally heard
about Mercy and was diagnosed with diabetes by Pamela Williams, a staff physician,
Brown recalls, “she started telling me what could happen — amputation, kidney
failure, heart failure. I was like, ‘I could lose my foot, my hand?’ I had
never heard of anything like that.”
On a Mediterranean
diet, Brown, also a licensed pastor who does online counseling, has gone from
340 pounds to 215. His blood sugar has been under control the past few years.
“But unfortunately,
the damage was done when he didn’t have insurance,” Williams says.
With coverage from
Healthy Michigan, Brown sees a nephrologist for his chronic kidney disease, a
cardiologist for his congestive heart failure, an ophthalmologist for eye
damage — all downstream effects of the years he did not know he had
out-of-control diabetes.
Brown now has three
stents in his heart, including a new one this summer after he had balloon
angioplasty to open a clogged artery. He takes medicines that, if he had to pay
retail, would cost about $2,400 a month.
“This stuff was not
available to me without insurance,” Brown says. “I am grateful for it.”
****
Understanding the
ways the ACA has affected Americans’ health is a work in progress. In the law’s
first years, results were mixed, but signs of improvements have accelerated
lately, as people uninsured before now have more years of coverage, giving
researchers better data to study.
It is too soon to
know whether the patterns might reverse with new U.S. Census Bureau data showing that
the uninsured rate rose significantly last year for the first time since the
ACA has existed.
The findings that
exist are not perfect. One National Bureau of Economic Research paper in July,
looking at deaths from all causes among adults from their mid-50s to mid-60s,
found that dying in a given year has been significantly less common in the
states that expanded Medicaid. The paper said that perhaps 15,600 deaths could
have been avoided if the expansion had been nationwide, but it cautioned that
is a rough estimate in part because the study was unable to look specifically
at the people who signed up for Medicaid.
Similarly, a study last year found that infant deaths
— especially among black babies — were dropping more rapidly in parts of the
country that had expanded Medicaid. But the study does not distinguish families
that got coverage through the ACA expansions.
The University of Michigan work, including on
trends in hospital stays for four main chronic diseases, was able to focus
specifically on people who had joined Healthy Michigan. It found that from the
first year in the program to the second, hospital stays for asthma plummeted by
half and also fell for diabetes complications. But hospital stays for heart
failure became more common. The researchers have not yet looked at the patterns
for additional years.
Still, John Ayanian,
director of the University of Michigan’s Institute for Healthcare Policy and
Innovation, said, “the weight of evidence is on the positive side.”
No comments:
Post a Comment