I'm joined by over roy he's a Forbes columnist in Manhattan Institute senior
fellow he talks about the Medicaid expansion under Obamacare
in how medicaid fails the poor over it's really great to have you and I want it
kinda dig into do you make three different
claims one is that people with Medicaid have worse health outcomes than those
with private insurance
and no better outcomes than those with no insurance at all
you talk about medicaid not reimbursing
hospitals and you've also talked about
it being difficult for people on medicaid to get the care they need to if
it's okay with you
it's great to have you can we start with medicaid leading to worse health
outcomes than having no insurance
at all that seems hard to believe it does seem hard to believe until you
actually look at the medical literature
the medical literature is overwhelming on this point about
are how poor medicaid's help outcomes are
the best study we have on this and there are many
but the best study we have on this comes from the new england journal Medicine it
was a grouper
economist at MIT and Harvard that looked at a population Oregon
and I've written about this for my Forbes column
at the Apothecary and also its featured in the book this study that was on organ
among the people who had to sign up for a lottery
what to get who are uninsured to get medicaid because the Medicaid program in
organ had grown
to rapidly to the point where the state abortion ran outta money
and so they closed off the program's new enrollees
and had a lottery for the remaining slots
from the waitlist and so then what happened was there a budget people got
into the Medicaid program who won the lottery
effectively a randomized experiment and a bunch of people who didn't
and I'm I'm simplifying a great deal but basically what these economist ed
was they took those two groups and then tracked them over time to see if
medicaid
helped these individuals get better health outcomes
and they found much to their surprise not not to mind I'm afraid
that medicaid had no impact on health outcomes
it didn't may help people live longer it didn't reduce their rates of heart
disease
it didn't reduce their rates of diabetes and a whole host of other %uh factors
they looked at
and this was of course a big news you'd think but the media didn't highlighted
as much as perhaps they would have been a different political environment
yeah I look at that same study and I came away with a different take and I'll
just kinda tell you how I sighed and then maybe we can talk a little bit
about what may be where I'm going wrong or what I'm missing which is that
certainly we were just a step has to take a step back and say hey
if you look at random people who don't have insurance and compare them to
random people who have medicaid and compare health outcomes
that to me wouldn't be very valuable and I think you'll agree on this part
because
those who don't have insurance may not have insurance for different reasons
then simply they can't afford it because if they couldn't afford it
then they'd be able to get medicaid so that that we agree would not be a valid
comparison right
well it goes the other direction as well right so
your point is right which is that that
a lot of people uninsured are uninsured because they're poor
they're uninsured because insurance is a bad deal for them
there actual health anticipated health risk for health costs are relatively low
cuz a young and healthy
right and yet they're being asked to spend thousands of dollars on heavily
regulated insurance products that cover a lot of things that they don't need
so that is a big a part of the reason why there are so many people on a shirt
in america
and this study was focused more on the low-income population to your point
up but but that is still a very important thing to understand
right we spent $450 billion dollars a year that's billion with a B
on this program and it's not actually making people's health better
and have the coverage expansion that occurs under Obamacare
occurs through the Medicaid program randall make it let's do it let's not
get too far ahead so we agreed at least on the first part so then going back to
the Oregon study
that to me the promise made more sense which is rather than comparing people
who don't want insurance
to people who do and making broad comparisons about their health outcomes
we're just gonna take this group of 90,000 people all of whom had
self-selected as wanting to have medicaid
and we will compare how they do versus others now I don't know what numbers you
looked at
but the numbers I look that showed that the 10,000 people who who won
the medicaid lottery so to speak actually did have overall better health
outcomes than the 80,000
who were left outside have the proper the program so specifically
what data are you using their yeah I'm not really sure what you're referring to
there because that the study actually says right in the abstract
that there was no measured improvement in physical health outcomes
so when you see that lets let's for a second let's let's assume the Medicaid
program
let's say it's completely ineffective which maybe is not that far from
from what you believe do you think that that is the suggestion that we should
church we should eliminate the program altogether and that poor people
shouldn't have some kind of safety net health insurance system
or does it say to you that maybe the program isn't well enough funded or well
enough administered
what would be the solution in your mind is it simply to not have a program at
all
it so I'm really glad that you asked that question because this is
this is where the debate about medicaid has been so impoverished
right the the dichotomy that you hear on the left
has been well if you're a critic how medicaid works in a bureaucratic
up medicaid's poor health outcomes that must mean
that you actually hate the poor and want to demolish health care for the poor and
you oppose
subsidizing health coverage for the poor and to be clear to be clear I'm not
saying that in other words I genuinely want to know what is what is the
proposal
right so that's why I'm glad you asked the question because and I talk about
this in the book
at their the the key here is not that the point of this
a book and a point to this argument about medicaid's a poor health outcomes
is not to say
that we shouldn't a a marshal our resources together
to provide the poor with needed health care services it's that Medicaid doesn't
do this
that medicaid is a profound waste of money and that we could take
the same amount of money %uh if not less actually but you let's just say for the
sake of our meeting the same amount of money
and offer the poor far better health coverage
there were actually address their real health care needs and make them
healthier and actually provide
but beneficial health outcomes if we up
approached delivering those services in a completely different way which is to
say and set up giving them
the Medicaid program which for a lot of different reasons is broken and
dysfunctional
giving them the same for example the same kind of coverage that we see in the
Obamacare exchanges
so giving them tax credits or premium support payments that would allow them
to buy the same hi higher quality private coverage
but other low-income individuals will be able to gain
that also I know its exchange that's all well and good however
for those individuals who currently because I income
are not required to pay any premium are you okay with that being the financial
result under the exchanges as well in other words are you okay with a certain
income level at which no premium payment would be required
yeah I would say that I don't have real a a real problem with there being a
I'll and I mean I wouldn't say I wouldn't want to be 0
but if it works five or ten dollars you know I think I think you want them to
have some small skin in the game
I and if you look at for example in the way the AC exchanges work
if you're at that bottom and to the income wrong that's eligible for
exchange subsidies
your affectively paying almost no prime you're paying you know again something
like low double digits are single digits for you coverage if anything
okay so you've mentioned earlier and we have limited time saw kinda run this by
you give me your thoughts
you mentioned earlier that the false dichotomy that often exists from the
left when talking about this
one other things I often hear from the right and I talk to a lot of
conservatives on this show
is that based on any particular inefficiency or less than ideal
situation within
the Medicare or Medicaid system that is somehow proof that governments broadly
speaking simply cannot do the healthcare thing
you of course would agree that there are many countries around the world
that do it and do it well with incredibly high satisfaction level so
to say that it is simply government that can't do healthcare
would be empirically wrong correct yeah and in fact when I speak to conservative
audiences which I do with some frequency
I show them a slide were I show them all the different countries in the world and
how much the government so those countries spent on health care the
common side you see is
how much the total health care spending is around the world and how how we're
number one in that regard
but what I think a lot of conservatives don't realize is that government
spending on health care in the United States
is actually on a per capita basis the fourth-highest some in the world
in 2010 before the AC a was passed
and so my argument is it to conservatives is if you look at
countries like Switzerland Singapore which have universal coverage
but use a lot of more market-oriented reforms to achieve universal coverage
we can actually cover everyone have really good health outcomes
but also save the system in taxpayers a lot of money so I don't think universe
I think a lot of conservatives have come to believe that universal coverage is a
left this concept because the left has been are so vigorous an advocate at
universal coverage and
and my counter-argument to that has been universal coverage is now is not the
bogeyman
the bogeyman as how you achieve universal coverage in the way we've
with the way we've done the US has been profoundly an efficient and and there
are many avenues
for improving the system that would that utilize the best ideas from both sides
alright over Troy Forbes columnist Manhattan Institute senior fellow
the book is how medicaid fails the poor really great to have you on today
my pleasure thanks for having me