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Oregon study offers insight into the Affordable Care Act

by: CHRISTOPHER ONSTOTT/TRIBUNE PHOTO - Asthma sufferer Linda Monroy tries to breathe in air after using her inhaler. Ten years without health insurance and four years with have made Monroy part of a study that has national  implications.

Three weeks ago, Linda Monroy caught an upper respiratory bug, she thinks from her 11-year-old son Valentino.

Monroy suffers from asthma, so she promptly went to an urgent care clinic and came away with a prescription for Prednisone to open her airways. She felt ecstatic.

It wasn’t the medicine that lifted the Beaverton resident’s spirits. It was being able to visit a clinic, get medicine and not have to worry about the cost, or to consider heading to a hospital emergency room for treatment.

Four years ago, the 52-year-old Monroy became part of an experiment that has health care researchers showing renewed interest in Oregon since the U.S. Supreme Court upheld the Affordable Care Act on June 28. Monroy came up a winner in a lottery held when the Oregon Health Plan had 10,000 new slots for Medicaid health care coverage. After 12 years without coverage, she suddenly had health insurance.

The most significant element of the act will extend health care insurance to an estimated 30 million more Americans. For years, researchers have wondered what that might mean.

Health care providers could be stretched thin as uninsured people who received little health care now take advantage of their new status. But economists and hospitals have long made the case that the uninsured cost the health care system vast amounts of money by putting off health care until their conditions became severe and more costly to treat, and by repeatedly visiting emergency departments.

The Oregon Health Study provided an opportunity to examine those possibilities. Top researchers from across the country began comparing the lives and health care costs of Oregon Health Plan lottery winners such as Monroy with those who remained uninsured. An initial report was released a year ago, and the analysis continues.

Bill Wright, a Providence Health & Services researcher participating in the study, says two primary lessons so far are clear.

“A lot of folks have said Medicaid doesn’t do anything, and we found that it does,” Wright says. “And a lot of folks say you insure people it’s going to immediately pay for itself, and we found that it costs, at least initially.”

The newly insured low-income lottery winners used more health care than their still-uninsured counterparts — about 25 percent or $777 per year more. They received much more preventative care, including mammograms and cholesterol screenings. They entered hospitals 30 percent more frequently. Surprisingly, they did not go to emergency departments any less frequently than those who were uninsured.

Easing their minds

That last finding was a puzzler for researchers who have started interviewing study participants. Heidi Allen, another of the project’s researchers, says she was struck by how “judicious” the uninsured were in accessing health care. She recalls interviewing 10 uninsured Oregonians in a room who were promised $75 for taking the time for the interviews and hearing each one say he or she would take the stipend and use it for prescription drugs.

Allen also noted people who had won the lottery and obtained health insurance had a variety of attitudes about their good fortune.

“Everybody was glad to have it ... but some people were like, ‘Yeah, it just eases my mind,’ and some people said, ‘It was like winning the real lottery, it felt like winning a million dollars,’ “ Allen says.

One young man told Allen he worked construction jobs, but because he lacked insurance, he wouldn’t take jobs on rooftops anymore, for fear of falling and injuring himself. Having won the insurance lottery, the young man now said he would take those jobs.

Another said he had been afraid to ride his bike without insurance, and a third said he would join a basketball team again knowing he was insured. A woman told her she had cervical cancer but lacking insurance had not received treatment. That would change now that she was insured.

At death’s door

Linda Monroy’s experience is a bit like the Oregon Health Study in miniature. While she enrolled in the Oregon Health Plan four years ago, many of her friends remain uninsured, and she can see how the difference has played out in their CHRISTOPHER ONSTOTT/TRIBUNE PHOTO - Linda Monroy's medications for asthma and depression – paid for by the Oregon Health Plan – typically cost about $250 a month. But since gaining coverage, Monroy‚Äö's emergency department visits have practically disappeared.

Monroy works as a self-employed courier, driving around town delivering medical equipment, blood samples and documents for medical companies. She has five children, but Valentino is the youngest and the only one still living at home.

In 1995, she lost her health insurance, and she remained uninsured until winning the health plan lottery in 2008.

Monroy says during the 12 years she carried no health insurance, her asthma became far worse. For starters, she could not afford the prescription drug Advair, which costs about $350 per month. Occasionally she would find a friend who had some extra, a few times safety net clinics gave her some, and once the drug’s manufacturer gave her a free one-year supply after she wrote them.

But without regular medication, Monroy says, even colds were likely to blossom into respiratory crises. She estimates she would visit a hospital emergency department six to eight times a year.

“I would wait until I was at death’s doorstep and I couldn’t breathe,” she says. “The doctor would say, ‘Why did you wait so long?’ And I would say, ‘How do you expect me to pay for the medication and my appointment?’ “

Now insured, Monroy has visited an emergency department only once in the past year, when she couldn’t get in to see a physician during an asthma episode.

Happier people

But one of the mysteries of the initial Oregon Health Study data is that Monroy is not typical. Emergency department visits stayed about the same for those who enrolled in the Oregon Health Plan and those who remained uninsured.

Monroy isn’t surprised. Visiting the emergency department becomes a habit, she says, and visiting the emergency department with insurance is even better.

“You’ve been poor all your life and all of a sudden you have an insurance card, which is like money in your pocket,” she says, “and now you have the freedom to go to the emergency department in the middle of the night, rather than wait for the doctor in the morning. It’s almost like a high, because all of a sudden you’re an important person.”

Monroy says getting health insurance might have saved her life. Among the most revealing pieces of the health study is how having health insurance affected people’s outlooks on life. Overall happiness increased 30 percent among the people with insurance compared to those who remained without. MIT economist Amy Finkelstein, a member of the Oregon study’s research team, says the increased happiness was equivalent to doubling a person’s income. Finkelstein says a sense of security might be the reason.

The Oregon study found those who gained Oregon Health Plan insurance improved their financial status considerably, compared to those who remained uninsured. They had a 25 percent decline in unpaid medical bills sent to collection agents, for instance, and a 40 percent decline in borrowing money or not being able to pay bills on time.

“The key rationale for health insurance is not ‘I value health insurance because it will improve my health,’ but ‘I value health insurance because of the financial security it provides,’ “ Finkelstein says.

In addition to asthma, Monroy suffers from depression and occasional anxiety attacks. Uninsured, she couldn’t afford the medication that had been prescribed for these conditions. Now she takes it regularly. Researcher Allen says overall, people in the Oregon study who received health insurance reported significant mental health improvement.

“If insurance were a pharmaceutical product for depression, we would all be rich right now if we could sell it as a drug,” Allen says.

Monroy says she is certain her enrollment has saved money, despite the study’s finding that those who enrolled used 25 percent more in health care dollars than the uninsured. Her asthma and psychiatric medications combined cost about $250 a month. She says she visits a primary care physician about twice a year. Add to that about one emergency department visit per year.

Prior to gaining insurance, Monroy says her six to eight emergency department visits each year often cost $2,000 or more apiece. At one point while uninsured, she had accrued $50,000 in unpaid hospital and physician bills, most from her asthma-related emergency department visits, which led to her filing for bankruptcy.

Too embarrassed

Not everyone who was lucky enough to win the Oregon Health Plan lottery in 2008 jumped at the chance to become insured. Researchers say less than one in three lottery winners enrolled in the health plan.

According to Finkelstein, only about six of 10 who received letters notifying them that they could enroll returned the plan’s applications. Some found the lengthy forms too hard, she theorizes, and others either had moved out of state or knew the income they would have to report would make them ineligible. And some might have been reluctant to reveal they were not U.S. citizens.

Allen recalls interviewing a lottery winner who cleaned houses for a living. She had eight clients, and the enrollment form required her to have her clients report how much they each paid her. The woman didn’t like the idea all her clients would know she was applying for Medicaid. In the end, the housecleaner did not enroll.

“She said, ‘I was so embarrassed, I couldn’t even ask them,’ and she just let it go,” Allen says.

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