Obamacare’s Complicated Relationship with the Opioid Crisis

The opioid epidemic, having evolved into one of the greatest public health crises of our time, is a contentious aspect of the ongoing debate surrounding the Republican healthcare proposal.

Voices on the left worry that the repeal of Obamacare’s Medicaid expansion and essential health benefits would worsen the crisis by cutting off access to treatment for addiction and substance abuse. Mother Jones and Vox have both covered the issue. Former President Obama’s June 22nd Facebook post stated his hope that Senators looking to replace the ACA would ask themselves, “What will happen to the Americans grappling with opioid addiction who suddenly lose their coverage?”

On the other side of things, there are theories that the Affordable Care Act actually helped finance–and perhaps exacerbated–the opioid epidemic. It goes something like this: Expanded insurance coverage was taken as a primary goal of the ACA. Two of its policies that supported that goal–allowing adults up to 26 years of age to remain on their parents’ insurance and expanding Medicaid to cover a greater percentage of the population–unintentionally connected at-risk cohorts (chronically unemployed prime-age men and young, previously uninsured whites with an appetite for drugs, to name two) with the means to obtain highly addictive and liberally-prescribed pain medications at a fraction of their street price. (Some knowledge about labor force and other social trends helps paint a clearer picture on this.) Once addicted, many moved on to cheaper and more dangerous alternatives, like heroin or synthetic opioids, thus driving the growth in overdose deaths.

This is a really interesting, if tragic, narrative, so I decided to take a look. I focused on state-level analysis by comparing CDC Wonder data on drug-induced deaths with Kaiser Family Foundation data on expansion status and growth in Medicaid enrollment. The graph below plots states based on their rates of growth in Medicaid rolls and overdose deaths from 2010 to 2015, and is color-coded for expansion status: blue for states that expanded coverage before or by 2015, yellow for states that expanded during 2015, and red for states that hadn’t expanded by the end of 2015. (A note: this isn’t an original idea; for a more in-depth analysis, check out this post.)

What’s interesting is the places where overdoses have increased the quickest. The fastest growing rates of overdose deaths were mostly in states that had expanded Medicaid by 2015; the only non-expansion state to grow by more than 50% since 2010 was Virginia, which in 2015 still had a relatively low rate of 12.7 fatal overdoses per 100,000 population. For some perspective on how bad things have gotten, that rate would have been the 19th highest among states in 2005; today Virginia ranks 42nd in terms of OD rate.

On the other hand, there isn’t a noticeable correlation between increases in Medicaid coverage and increases in the rate of fatal overdoses. Additionally, the rates of overdose deaths in expansion states were increasing before many of the Affordable Care Act’s key provisions went into effect. Starting around 2010, there was a dramatic divergence between would-be expansion states and the rest. It’s possible that states with accelerating rates were more likely to expand coverage in response to increased frequency of fatal overdoses.

So what’s the deal? Did the Affordable Care Act agitate the opioid epidemic? Obviously I don’t have the answer to that, but here’s my take:

I think it would be difficult to argue it hasn’t been a factor on some level, given the far-higher rates of prescription, death, and opioid use and among Medicaid patients than the general population, as well as the state-level trends in OD rates (with acknowledgement that state-level analysis is pretty clunky in this regard; for many reasons West Virginia’s population isn’t really comparable to California’s). I think the fact that state Medicaid programs are adjusting regulations for painkiller prescriptions is an acknowledgement of that.

But if the ACA had a negative effect, I’d think it must register as a drop in the bucket. There are so many pieces to this story: lax prescription practices and the rise of “pill mills,” declining labor force participation, sophisticated distribution networks of Mexican heroin, bogus research and marketing on pain management, stark disparities between expectations and reality. It’s nice to think there’s one thing we can change to solve everything, but I don’t think we’re going to be so lucky.

Here’s another twist: Even if the Affordable Care Act had some negative impact, it could very well be that ACA repeal could make things worse. Scrapping essential benefits coverage could lead to a loss or reduction of access to addiction treatment for millions of Americans. Moreover, gaining insurance has been shown to alleviate feelings of depression and anxiety. How then, might we guess 20 million Americans will feel after losing their insurance? Given the feedback loop between pain and depression, this question deserves a lot of deliberation.

Insurance Coverage Numbers Are Important, But Not All-Important

Whether you’re into this sort of thing or not, you’ve probably been hearing a lot about healthcare policy these days. Public debate has roiled as Republican lawmakers attempt to make good on their seven-year promise to repeal and replace the Affordable Care Act (ACA). As the debate rages on, one metric in particular appears to hold outsize importance for the American people: the number of Americans covered by health insurance.

Analysis by the Congressional Budget Office, which showed that 14 million more Americans could lose coverage by 2018 under the Republican replacement, caused intense public outcry and was frequently cited as a rationale for not abandoning the ACA. There is immense political pressure not to take actions that will lead to a large loss of coverage.

But here’s the thing: the relevant metric by which to judge Obamacare isn’t insurance coverage numbers. To do so is to move the goal posts and place undue importance on a number that might not be as significant as we imagine.

The ultimate point of health insurance, and the implied rationale for manipulating insurance markets to cover sicker people, is that people will use insurance as a means by which to improve their health, not just carry a plastic card in their wallets.

Health Insurance ≠ Health

The impulse to use insurance coverage as a proxy for health is misguided but understandable. For one thing, it’s a simple, single number that has dropped precipitously since the implementation of the ACA; that makes it a great marketing piece for supporters. For another, health insurance is the mechanism by which most of us pay for most of our healthcare.

And yet in 2015 the uninsured rate fell to 10.5% (down from 16.4% in 2005) while age-adjusted mortality increased for the first time in a decade.

It turns out a nominal increase in the amount of insured Americans doesn’t necessarily translate into improved health outcomes for those individuals. A newly released paper from the National Bureau of Economic Research (NBER) finds that while the ACA has improved access to healthcare, “no statistically significant effects on risky behaviors or self-assessed health” can be detected among the population (beyond a slight uptick in self-reported health in patients over 65).

These results are consistent with other studies, like the Oregon Medicaid Experiment, which found no improvement in patients’ blood pressure, cholesterol, or cardiovascular risk after enrolling them in medicaid, even though they were far more likely to see a doctor. There were, however, some notable-but-mild psychic benefits, such as a reduction in depression and stress in enrollees.

In short, despite gains in coverage, we haven’t much improved the physical health of the average American, which is ostensibly the objective of the ACA.

Why Not?

To be fair, the ACA is relatively young; most of its provisions didn’t go into effect until 2014. It may well be that more time needs to pass before we start to see a positive effect on people’s health. But there are a few reasons to think those health benefits may never materialize–at least, not to a great extent.

A lot of what plagues modern Americans (especially the poorest Americans) has more to do with behavior and environment than access to a doctor. Health insurance can be a lifesaver if you need help paying for antiretroviral medication, but it won’t stop you from living in a neighborhood with a high rate of violent crime. It won’t make you exercise, or change your diet, or stop you from smoking. It won’t force you to take your medicine or stop you from abusing opioids, and it certainly won’t change how you commute to work (that’s a reference to the rapid increase in traffic deaths in 2015).

Here’s something to consider: A lot of the variables that correlate to health–like income and education–also correlate to the likelihood of having health insurance. If we want healthier Americans, there may be more efficient ways to achieve that than expanding insurance coverage, like improving employment and educational opportunities. Maybe something creative, like Oklahoma City’s quest to become more walker-friendly, could yield better results?

Of course, all things being equal, more insurance coverage is better. But nothing comes without cost, and as a society we want to be sure that benefits justify costs. So far, that’s not clear. This poses an existential question about our current pursuit of universal coverage, and, by extension, the relevance of coverage as a metric for the success of healthcare policy: If insurance isn’t the cure, why are we prescribing it with such zeal?

The CBO Feels the Love

The Congressional Budget Office isn’t known for its awesome marketing or pithy statements. It’s never been recognized by Buzz Feed for its social media use. Nevertheless, the Congressional Budget Office (CBO) is enjoying an unusual amount of love on Twitter.

Here’s how you really know they’ve made it: The title of yesterday’s National Review Morning Jolt was, “The Congressional Box Office is Very ‘In’ Right Now.”

Two nights ago, it tweeted a four-word message with a link to its analysis of the American Health Care Act (AHCA) that has received far more attention than is normal for the CBO twitter account. As of writing this post, the tweet in question has racked up 62 responses, 846 retweets, and 542 likes.

That might not sound like a lot; the truth is, it isn’t. Donal Trump’s tweets, for example, often receive tens of thousands of ‘likes.’ But relative to the usual engagement on the CBO’s tweets, it’s absolutely ridiculous.

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Since January first of 2016, the CBO has tweeted 120 times. The median numbers of responses, retweets, and ‘likes’ to those tweets were respectively 0, 3, and 2. In fact, this latest tweet is responsible for nearly half of all the reactions garnered by the CBO’s account over that time period.

So what does this tell us?

The most obvious insight is that people are paying more attention to the CBO since the administration change. That’s not surprising; the CBO evaluates economic and budget proposals, and there are quite a few shakeups going on in that department right about now. The agency has been firing on all cylinders to keep up with demands from Congress, doubling the frequency of its tweets since Trump took office (.48 tweets/day compared with .24 tweets/day during the previous year).

In the final year of Barack Obama’s presidency, the CBO only averaged 9.5 ‘retweets’ per tweet–and that’s including a January 17th tweet that was responsible for 405 retweets alone (if you exclude that post, the account averaged 5 retweets per post). Since the beginning of the Trump administration, that average has jumped to 39.6 (7.6 if you don’t include the latest viral tweet).

Another insight: Negative feelings about the AHCA are driving the CBO’s recent popularity surge. The only two tweets with significant activity in the past year (look at the spikes in the graphs above) were about the AHCA and the effects of repealing the Affordable Care Act (ACA). A cursory glance through the responses to both tweets reveals that most of the commenters are detractors of the current administration who oppose changes to the ACA.

It would be a mistake to use this as a proxy for national consensus on the AHCA, however. Twitter often skews liberal.

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For the record, the CBO writes a killer blog (I use the term loosely, for obvious reasons). It’s a great source of unfiltered information about economic ideas from Washington. You can sign up to receive email updates from it here. And, if the CBO is reading this, don’t forget about us when you get famous.

The Lost Art of Debate

This recent election cycle has been nothing if not revelatory. Who would have guessed that Bernie Sanders and Donald Trump were the harbingers of a populist revolt that would leave both major parties in the throes of identity crisis?

But enough punditry; those are considerations for the political class. While they meet behind closed doors in Washington, We the People should revisit the ancient and sacred art of civil debate and contemplate why so many of us abandoned it.

This isn’t to say that people haven’t fought for what they believe in. Indeed, part of the problem is that many of us confuse fighting with debate. Debate requires patience, empathy, clarity, and above all, an open mind. Fighting requires very little beyond the hubris to mistake conviction for virtue (for examples, visit Facebook, YouTube, or twitter).

To debate someone you have to respect them enough to let them finish a sentence. You have to be willing to let them construct an argument against you under the assumption that you will later be able to successfully challenge its premise. You must also open yourself to the idea that there are realistic limits to your own knowledge and perception.

The bravest thing you can do is give someone time to speak against you. Conversely, resorting to ad hominem, laying waste to innumerable straw men, and shutting out dissent are the strategies of cowards: the easy way out.

Too often these days we lack the bravery to face our ideological opponents. We go online and read news sources that confirm our opinions; we shame our detractors into silence; we withdraw to be with our own kind. Consider that this year over 1,700 counties voted with margins 20 points different than the national vote while only around 250 voted within 5 points of the national vote. At the Washington Post, Phillip Bump writes that two thirds of Clinton and Trump supporters had few to no friends supporting the other candidate. The lukewarm comfort of our echo chambers keeps us content to ignore that ours is a big world.

Nowhere has this tendency become as evident as on college campuses, which have sadly become ideologically homogeneous to the point of enfeeblement. Recently, colleges have developed a disturbing trend of turning away controversial speakers at the request of students. Between 2015 and 2016, the Foundation for Individual Rights in Education counts 52 attempts to disinvite speakers based on student opposition, of which 24 were successful.

Following the election of Donald Trump, there was a widespread and embarrassing exhibition of incredulity. The dangers and consequences of the echo chamber were made apparent.

Rather than take this as an opportunity for introspection, some have chosen to double down. More than a few colleges granted accommodations to their students, ranging from postponing exams to providing “breathing spaces”—rooms containing pets and coloring books—to students who felt stressed by the results. Many smart people took to social media to excoriate others they’d never met, or tried to understand. Is it any wonder that those who have shied from ideological opposition wither in its face?

A closed mind cannot aspire to persuasion. A theory is not made stronger without facing resistance. If you want people to listen to you, as presumably we all do, you should be willing to hear them out. That means reading news from sources that make you uncomfortable and trying to engage people who aren’t like you without writing them off as bigots. It means reaffirming the value of unpopular speech, denouncing censorship, and moving past identity politics. It won’t be easy, but it will be worth it.

For the good of our society, it’s time to revive the art of debate and put aside the intellectual lethargy that precludes it.

No, Voting Third Party Isn’t a Waste

Given the historically unpopular candidates presented to us, 2016 should be the year Americans are encouraged to expand our political horizons.

Instead, people interested in a non-binary choice this election face a litany of derisions and insistences that their political preferences should take a back seat to a greater mission of ensuring that either Clinton or Trump not take the White House.

Underneath it all is the accusation—outright or implied—that voting for a third party candidate is a waste of time: a selfish, brazen gesture best left for a less pivotal year.

This is a terrible argument. There’s no such thing as wasting your vote if you’re doing what you want with it: it’s yours! Vote for candidate A, B, or C; don’t vote; write in your uncle’s name. It doesn’t matter. The only real way to waste your vote is to let someone else tell you how to use it.

Once you’ve been dutifully informed by some clairvoyant pundit that you’re wasting your vote by using it the way you want to, the dismissal of third party candidates based on their remote chances of victory is never far behind. This is profoundly confused; a vote isn’t a bet. There’s no prize for picking the candidate that ends up winning.

The point of a representative democracy–other than to elect leaders–is to convey national preferences to politicians (does anyone believe Ralph Nader’s relative success as a Green Party candidate had no impact on the Democrats’ current environmental stances?). The best way to do this is for everyone to vote for candidates and ideas that appeal to them. The worst thing voters can do is reward unresponsive parties with loyalty: that only begets more unresponsiveness.

Increased interest in third parties let’s Democrats and Republicans know they’re off track. In that sense, and especially to anyone interested in the integrity and evolution of our political discourse, third parties have an important role as the barometers of American political attitudes, if not yet heavyweight contenders for the presidency.

Remember: only a very small minority of our country has actually voted for Clinton or Trump at this point! There’s no reason for the rest of us, who have actively or passively declared our disinterest in both, to feel pressured to line up behind either of them. Some will, and that’s fine if it’s what they want at the end of the day; in fact, I’m happy they’ve found something they can believe in. But it’s not unreasonable for the rest of us to pursue options that we find more personally appealing.

Pluralism and diversity are, at least ostensibly, integral to the American political experience. I can think of nothing worse for our nation than a fear-driven dichotomy whereby we are encouraged to re-imagine second worst as synonymous with best. If we want to be happy with the results of our electoral process, we should start by being more honest about what we want from politicians. The best way to do that is in the voting booth.