NEW YORK — The Affordable Care Act has provided health insurance to some 20 million people. But are they any better off?
This has been the central question as we've been watching the complex and expensive health law unfurl. We knew the law was giving people coverage, but information about whether it's protecting people from debt or helping them become more healthy has been slower to emerge.
A few recent studies suggest that people have become less likely to have medical debt or to postpone care because of cost.
They are also more likely to have a regular doctor and to be getting preventive health services like vaccines and cancer screenings.
A study published Monday in JAMA Internal Medicine offers another way of looking at the issue. Low-income people in Arkansas and Kentucky, which expanded Medicaid insurance to everyone below a certain income threshold, appear to be healthier than their peers in Texas, which did not expand.
The study took advantage of what Dr. Benjamin Sommers, an author of the paper and an assistant professor of health policy and economics at Harvard, called "a huge natural experiment."
In its 2012 ruling, the Supreme Court made the health law's Medicaid expansion optional for states. The resulting variation in choices makes it much easier to compare what happened in different states and draw conclusions about what effects health insurance coverage might have for the finances and health of Americans.
The researchers gathered their results by conducting a large telephone survey of low-income residents of the three states. They asked the same questions three times: in 2013, before the law's Medicaid expansion; at the end of 2014, after it had been in place for a year; and at the end of last year. Then they compared what happened over time, using Texas as a kind of control group to see how much of a difference the Medicaid expansions in the other two states made.
Their survey found people in Arkansas and Kentucky were nearly 5 percent more likely than their peers in Texas to say they were in excellent health in 2015. And that difference was bigger than it had been the year before.
No two states are exactly the same, of course. There are many differences between Texas, Arkansas and Kentucky, besides their decisions on this part of the Affordable Care Act. The authors cautioned that their results can't prove that Medicaid expansion caused people to be healthier.
There are differences between Arkansas and Kentucky, as well. Kentucky expanded Medicaid in a more conventional way, while Arkansas tried an innovative expansion, offering its low-income residents private insurance. But the study found only small differences between the two approaches.
That finding may be of interest to states that have not expanded yet but are considering it. Louisiana this summer became the 31st state to expand its program, using an approach more like Kentucky's. And Kentucky's governor has considered revamping the program there to make it more like the one in Arkansas.
It might sound simple to measure whether people are healthier than they used to be, but it's actually pretty tough. While tests can tell you whether someone has high cholesterol, say, or high blood pressure, a single test may not tell the whole story. It turns out, however, that if you ask people how healthy they are, they do a pretty good job of telling you. Extensive research shows that people who say they are in poor health really are much more likely to die than those who describe their health as good.
The survey also asked about other subjects. It found that people in the expansion states were more likely to have a doctor and to have a place to go for care. They said they were more likely to have their chronic disease treated, and that they were more likely to have received screening for high cholesterol or high blood sugar, markers for heart disease and diabetes.
On financial measures, the study was in line with some previous studies, finding that people in Kentucky and Arkansas were less likely to postpone care or avoid taking prescribed drugs because of the cost, and that they were less likely to be struggling with a medical bill.
On almost all measures in the survey, the size of the difference between Texas and the other states was bigger in 2015 than it was in 2014. That trend makes some sense: Once you get health insurance, it might take a while before you start getting health care, and even longer before you'll start getting healthier (optimistically assuming that you do). But the trend suggests that we may need to wait some time in evaluating the health law's effects before we really know how big they are.
For those of us trying to evaluate the law, the slowness of results is frustrating. Still, Tuesday's study is quick by the standards of academic research. Big government surveys are asking some of the same questions posed by the Harvard researchers, but we're still waiting for their data from last year. Amy Finkelstein, an economist at the Massachusetts Institute of Technology and an author on the Oregon work, described the three-state survey as "entrepreneurial," because it gives us an early glimpse at these important questions.
It will take more time, and more research, to be sure whether the Affordable Care Act really is making Americans healthier and more secure.