The study's authors noted that Massachusetts isn't like the rest of the country. The state is awash in high-quality physicians and hospitals. Other factors may have influenced the results. For instance, the coverage expansion focused public attention on the health benefits of better diets, more exercise and quitting smoking.
But the data revealed that the mortality reduction came from fewer people dying of cancer, heart disease and infections. These are the very conditions where health insurance makes a difference by offering preventive services and faster access to care when disease strikes.
It will take years before we will have definitive evidence on the health effects of expanding insurance coverage under the Patient Protection and Affordable Care Act. But fortunately, for the researchers who will be asking that question, the nation is now engaged in a great natural experiment that should provide the answer.
About half the states have failed to expand Medicaid. Their relative performance on mortality compared with those states that did expand coverage—especially when those states have fairly similar economies, cultures and demographics like, say, Texas versus Arizona or Wisconsin versus Illinois—should be dispositive.
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While we're on the side effects of reform, it was interesting to see last week that two courageous senators—one from each side of the aisle—introduced legislation that would bring back death panels. Whoops. What I meant to say was legislation that would encourage seniors to develop advance directives for end-of-life care.
The notion that physicians should be reimbursed for advising their patients who want to develop advance directives was included in an earlier draft of the Affordable Care Act legislation. Initial drafts included a payment of $60 for the office session.
No one would have been required to create a directive as a result of the visit. Nor did the law specify what should be included in the advance directive. If someone wanted to be “plugged into the wall” (a great line from the movie “Beasts of the Southern Wild”), they could so specify and the physician adviser would still have gotten paid.
Still, that innocuous provision didn't stop anti-reform politicians from scaring seniors with the charge that Obamacare would create “death panels.” It quickly disappeared from the bill.
Now Sens. Tom Coburn (R-Okla.) and Chris Coons (D-Del.) have come up with a slightly different approach to encouraging advance directives. Rather than pay doctors, they would have Medicare pay $75 directly to any senior who writes an advance directive and makes it available to their caregivers.
The proposed law—“definitely designed to avoid pushback,” an aide to Dr. Coburn told me last week—would turn the advisory role over to organizations that exist in 43 states to promote the physician orders for life-sustaining treatment (POLST) paradigm. What began in Oregon in 1991 now has become a national clearinghouse with sample forms and a staff that's eager to help local groups promoting end-of-life directives.
Still, the biggest problem with end-of-life directives is getting them used. Many providers don't know they exist when critical choices have to be made. Many family members may be in the same position, or disagree with the choices made by their loved ones.
The POLST paradigm endorsed by the Coburn-Coons proposal turns the end-of-life directive into an actionable medical order housed in a not-for-profit organization that can be easily accessed by caregivers. Whether that's practical needs to be hashed out in congressional hearings. In a midterm election year where attacks on the ACA will be front and center, don't hold your breath waiting for that to happen.
Follow Merrill Goozner on Twitter: @MHgoozner
