Obamacare Is Killing People
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So the Republicans are murdering tens of thousands of people with their Obamacare replacement, according to the headlines and tweets I keep seeing.

I think they’ve got it backwards, though. It’s Obamacare that’s killing people, and just two classes of states are showing any immunity. Deaths from opiate overdoses are on the rise across the country, except in states that either legalized marijuana or declined Obamacare’s Medicaid expansion.

At first, I thought these extravagant claims of murder and mayhem were the work of Bernie bros uninterested in policy or nuance. They’re obviously unserious, based on an old game called statistical murder, where a budgetary or policy decision that results in more deaths than an alternative is blamed in severe terms.

In real life, the Republican health care bill is the mildest of reforms, meant to curb the number of idle young men inscribed in Medicaid. The Democrats would have accepted every bit of it had it come from the last administration.

But the exercise that the left is pretending to do — considering opportunity costs — is always worthwhile. Should we spend $616 billion on health care? On policing? On vehicle safety improvements? What will save the most lives?

Of course, if you want to get the most bang for your buck, you should follow President George W. Bush’s lead, and send money to places so desperately poor that very basic things like mosquito nets and clean water save millions of lives. But foreign aid is unpopular and our needs at home are many; politicians are not murderers for responding to their constituents’ demands.

Also, the exercise only gets you so far, even for folks more serious than Democratic lawmakers. The answers have a way of slipping off into the statistical noise. In fact, the numbers the Democrats are using here come from an analysis that recognizes it’s still an open question whether there’s any mortality rate increase associated with being uninsured.

“One (study) concluded that lacking coverage was a strong independent risk factor for death, whereas another found that coverage was only a proxy for risk factors such as socioeconomic status and health-related behaviors,” its authors write.

There’s one truly randomized study of the matter, out of Oregon, that’s rather famous for finding that the health benefits of Medicaid were almost indistinguishable from being uninsured.

I tend to find these areas rather dreary reading. If the experts can’t suss anything conclusive out of their multi-variable regression analysis, I don’t expect to find much to remark on.

But there are two points that seem obvious to me — patterns or correlations in the data that are so clear that it’s remarkable they haven’t been noticed more widely.

One, the Republican Obamacare replacement bill is not going to produce anything like 22 million new uninsured people, much less kill tens of thousands of them. Two, Obamacare’s expansion of Medicaid is connected to the opiate overdose crisis.

The health care expert Avik Roy has explained why the Congressional Budget Office’s estimate of 22 million new uninsured is almost certainly faulty. The CBO has scored three different Obamacare replacement bills over the last two years, ranging from the vetoed full repeal of 2015 to the current Senate bill, finding that each would cause between 22 million and 23 million uninsured.

The current Senate bill would spend $616 billion more on insurance than the full repeal, yet the CBO finds that the results would be identical. Wasteful as the federal government is, it isn’t going to manage to dump $616 billion on insurance without having any effect at all.

The CBO is basing its opinion on the repeal of the individual mandate, Roy says, imagining that millions will stop buying insurance once they’re not required to. But the IRS isn’t even enforcing the individual mandate now. In fact, Jonathan Gruber, one of the architects of Obamacare, has found that “the individual mandate’s exemptions and penalties had little impact on coverage rates.”

It’s obvious that the CBO is working from a very mistaken assumption.

The other point is less certain — somebody would have to run the regression analysis to verify the correlation — but it’s clear to me that opiate overdoses are increasing the fastest in states that a) expanded Medicaid under Obamacare and b) resisted the legalization of marijuana.

Opiate deaths have been on the steady increase, with fatal drug overdoses tripling since 1999. Much of that growth has come in the last few years. From 2010 to 2015, the opiate death rate in the U.S. increased from 12.3 per 100,000 population in 2010 to 16.3 in 2015, according to a study by the Centers for Disease Control. Of the 52,404 fatal US drug overdoses in 2015, 63 percent of them involved an opioid.

Obamacare’s Medicaid expansion and individual insurance exchanges both went into effect in 2014. In just the next year, the fatal opioid overdose rate increased by 15.6 percent, CDC found. Correlation, of course, is not causation, but the pattern is persistent.

The increase isn’t uniform. It’s clearly happening in 30 states, most of which accepted the Medicaid expansion. But overdose deaths have remained steady in 19 other states, according to the CDC. A graphic makes the difference utterly clear — overdose numbers are going crazy in some states, and remain flat in others.

Almost every one of those other states either a) resisted Medicaid expansion and it’s abundant opiate prescriptions or b) allowed its citizens a safer alternative for getting high.

If you compare the graphic from the CDC with a map of states that have resisted Medicaid expansion and another map of states that have effectively or actually legalized marijuana, there’s a clear if imperfect pattern.

Texas, Nebraska, South Dakota, Kansas, Mississippi, Georgia, Idaho, Wisconsin, South Carolina, Florida, Wyoming, Missouri, and Oklahoma all rejected the Medicaid expansion, and all have seen negligible growth in opiate overdoses.

Hawaii, California, Oregon, Montana, Arkansas, Washington, Colorado, Florida, Nevada, New Mexico, and Arizona have all legalized marijuana in some form, and have also seen little or no growth in overdoses.

States such as West Virginia and Kentucky accepted Obamacare, and have seen massive growth in opiate deaths. Likewise, many Obamacare-embracing states in the Midwest and Northeast have only begun to liberalize their marijuana regimes somewhat in the last year or so. These include New Hampshire, Ohio, Massachusetts, New York, Illinois, Rhode Island, Pennsylvania, and Minnesota. They’ve all got opiate problems.

So how could Obamacare be connected to the overdose epidemic?

Obamacare, of course, is mostly an expansion of Medicaid — to healthy adults, in particular. Of the 20 million people who gained insurance coverage under Obamacare, some 14.5 million people got their coverage from Medicaid or the Children’s Health Insurance Program.

A study by the Rand Corporation found that people who gained insurance through Medicare filled 79 percent more prescriptions than before. Another CDC study found that almost half of fatal drug overdose cases were people on Medicaid.

A quarter of all Medicaid patients take opiates, and 40 percent of those misuse the drug, other studies have found.

Time magazine has reported that Obamacare’s patient satisfaction survey, which includes questions such as, “How often was your pain well-controlled?” has created even more pressure for doctors to write prescriptions.

In short, Medicaid is part of the problem, supplying and subsidizing the distribution of billions of pain pills, many of which the black market redistributes. Aimless young people, it seems, will take free drugs if they’re offered, but they prefer the safer alternative.

A University of California San Diego study found exactly what I saw in those maps. In states that offered medical marijuana, the rate of painkiller abuse dropped 23 percent, and opioid overdoses dropped by 13 percent. A previous study found a drop of 25 percent. Those numbers might not sound like much, until you remember that the overdose rate is doubling in other states.

If Medicaid, then, is relatively ineffective at improving health outcomes, and it exacerbates an overdose epidemic, the Senate Republicans are right to tamp down some of the incentives for Medicaid expansion.

Their bill is far from the repeal-and-replace that Republicans have been promising, but even a modest reform, a cap having to do with per capita growth rates and such, would be an improvement on the status quo.

Otherwise, we’ll soon come to know Obamacare as Opiocare.

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