A lottery for Medicaid enrollment simulates a randomized trial.
In 2008, Oregon modestly expanded its Medicaid program through a lottery. From a list of 90,000 names on a Medicaid waiting list, 30,000 were drawn randomly; ultimately, about 10,000 of the lottery “winners” applied for state Medicaid services and were enrolled. Eligibility was based on age (19–64) and financial need (income, <100% of the federal poverty level; assets,
Researchers compared selected 2-year outcomes for about 6000 people who acquired Medicaid coverage through the lottery and for 6000 controls (people who entered the lottery but weren’t selected). Data were acquired by questionnaires and by limited cardiovascular risk assessments. The following statistically significant outcomes were noted in the Medicaid group, compared with controls:
- Lower prevalence of positive depression screens (21% vs. 30%)
- Better self-reported health-related quality of life
- Fewer financial hardships due to medical expenses
- Better access to medical care
- More Pap smears and mammograms completed
- More outpatient visits but not hospital admissions
Mean blood pressure, lipid levels, and glycosylated hemoglobin (HbA1c) levels were similar in the two groups.
Comment: One month ago, I saw an uninsured 45-year-old woman who had noted an enlarging breast mass for 9 months. She had not sought medical attention because “it wasn’t the cost of the mammogram or biopsy that concerned me . . . it was the cost of what would happen next if I have cancer.” Unfortunately, a biopsy showed breast cancer.
This case exemplifies a key reason for medical insurance — it enables people to access medical care when they need it, without fear of financial ruin. By that standard, the Oregon experiment is a success for Medicaid expansion. The lack of difference in cardiovascular risk factors is not important, given the short follow-up and the relatively normal values: Mean blood pressure, total cholesterol levels, and HbA1c in both groups were about 120/75 mm Hg, 200 mg/dL, and 5.3%, respectively.