Which Health Policies Actually Work?

Summary

This video discusses the rarity of rigorous evaluations in U.S. health care policy, despite vast spending. It highlights a few significant randomized studies, such as the Oregon Medicaid expansion and the RAND health insurance experiment, that influenced policy for years. However, the majority of health policy evaluations lack randomized designs, limiting their effectiveness. The episode also critiques voluntary participation in policy programs, which often skews results. The video calls for more rigorous policy evaluations and greater attention to evidence-based decision-making in health care reform.

Takeaways

• 💸 Less than 0.1% of healthcare spending in the U.S. is dedicated to evaluating health policies.
• 📊 Randomized controlled trials (RCTs) are the gold standard for evaluating healthcare interventions, but only 18% of healthcare policy studies use them.
• 🎲 Oregon’s Medicaid expansion lottery provided a rare opportunity for a randomized policy evaluation, influencing debates on Medicaid expansion.
• 🧠 Findings from the Oregon Medicaid study suggest Medicaid increases access to care, reduces financial hardship, and lowers depression rates.
• 🔍 The lack of strong evidence for improved health outcomes in some cases is used to argue that Medicaid may be ineffective.
• 🏥 Randomized health policy studies like the RAND Health Insurance Experiment have shaped healthcare design, such as deductibles and co-payments.
• ⚠️ Many healthcare policy studies lack rigorous designs, which affects the reliability of conclusions.
• 🚑 Programs like Medicare and Medicaid Innovation pilots often rely on voluntary participation, which introduces bias and reduces the impact of findings.
• 🏆 Bundled payment programs show promise, but lack randomization and participation challenges limit their learning potential.
• 📉 Government programs are rarely evaluated rigorously, making it difficult to end ineffective policies or scale successful ones.

Q & A

What was the main health policy change discussed in the video?

The main health policy change discussed was the random extension of Medicaid coverage to some low-income adults in Oregon, allowing researchers to track the impact of the policy.

Why are evaluations of health policies in the U.S. rare?

Evaluations of health policies are rare because less than 0.1% of total healthcare spending in the U.S. is devoted to evaluating which health policies work and which do not.

What is the gold standard for health policy evaluations, and why is it rarely used?

Randomized controlled trials (RCTs) are considered the gold standard for health policy evaluations, but they are rarely used because of the complexity, cost, and difficulty in maintaining these trials.

What was the key finding of the Oregon Medicaid experiment?

The Oregon Medicaid experiment found that Medicaid increases access to care, reduces financial hardship, and lowers rates of depression, but did not show statistically significant improvements in other health outcomes.

What was the RAND Health Insurance Experiment, and why is it significant?

The RAND Health Insurance Experiment, conducted in the 1970s, randomly assigned families to different levels of healthcare cost-sharing. It found that higher out-of-pocket costs led to less healthcare usage without short-term adverse health effects, except for poorer and sicker families. This study has influenced healthcare insurance design, particularly co-payments and deductibles.

What challenges do voluntary health policy programs face?

Voluntary health policy programs face challenges such as selection bias, where only certain healthcare organizations participate, and diminishing participation, as seen in the Accountable Care Organization program, which saw a steep drop in participants over time.

What issue arises from the lack of randomized designs in the Center for Medicare and Medicaid Innovation's programs?

The lack of randomized designs in many of the Center for Medicare and Medicaid Innovation's programs limits the reliability of findings, reducing the ability to rigorously evaluate the impact of new payment methods aimed at enhancing quality and reducing spending.

What is an example of incorrect thinking in healthcare policy based on low-rigor studies?

An example is the belief that wellness programs reduce employer healthcare costs, which was supported by low-rigor studies. However, when subjected to randomized controlled trials, these findings did not hold up.

What is the Foundations for Evidence-Based Policymaking Act, and how could it help improve health policy evaluations?

The Foundations for Evidence-Based Policymaking Act aims to improve data collection on government programs and requires agencies to develop methods for evaluating these programs, potentially leading to more rigorous health policy evaluations.

Why are health policy evaluations important for decision-making?

Health policy evaluations are important because they provide solid evidence to inform decisions on programs like Medicaid or Medicare, ensuring that policies are based on data and effectiveness rather than assumptions or political agendas.