Playing the Oregon health insurance lottery Health coverage in the USA is not universal. A contributing factor is that one in six people do not have health insurance, and the out-of-pocket costs of receiving timely treatment can be prohibitive.1 To reform US health care, President Barack Obama enacted the Patient Protection and Aﬀordable Care Act, colloquially known as Obamacare, in 2010.2 According to this law, children, parents, and adults without children who are not entitled to Medicare and who have family incomes of up to 133% of the federal poverty line are eligible for Medicaid, in opted-in states, as of Jan 1, 2014. Although the political struggles around Obamacare have been well publicised, evidence about the eﬀects of increasing eligibility for Medicaid on, for example, recipients and health services has been less prominent. The Oregon Health Insurance Experiment made use of randomisation in the form of a lottery to allocate Medicaid privileges, or not, to people on a waiting list. Sarah Taubman and colleagues3 now report that people on low income who received coverage as part of a small expansion of Medicaid visited the emergency department more often than did those who did not during March 10, 2008, to Sept 30, 2009 (estimated eﬀect of Medicaid coverage 0·41 additional visits [SE 0·12] vs 1·02 mean visits per person in the control group [SD 2·63]). Notable advantages of this study are the use of administrative data from emergency departments that are more accurate than are patientreported data, and the study design that enabled the investigators to minimise confounding factors.
An increase in emergency department use could indicate that, despite having Medicaid, individuals had diﬃculty accessing other health-care services or were advised to go to the emergency department. Using data from the 1999–2009 National Health Interview Survey, Cheung and colleagues4 reported that more people with Medicaid had at least one barrier to accessing primary care than did those with private insurance (16·3% vs 8·9%). Although many people will ﬁnd the allocation of health provision by lottery distasteful, the Oregon experiment has provided useful information about the use of health resources and the eﬀects on health and other outcomes.5 This evidence should prove powerful as plans are drawn up for the more inclusive US health system of the future. Farhat Yaqub The Lancet, London NW1 7BY, UK [email protected]
Rice T, Rosenau P, Unruh LY, Barnes AJ, Saltman RB, van Gineken E. United States of America: health system review. Health Syst Transit 2013; 15: 1–431. Democratic Policy and Communications Center. Patient Protection and Aﬀordable Care Act. Detailed summary. 2010. http://www.dpc.senate.gov/ healthreformbill/healthbill04.pdf (accessed Feb 8, 2014). Taubman SL, Allen HL, Wright BJ, Baicker K, Finkelstein AN. Medicaid increases emergency-department use: evidence from Oregon’s Health Insurance Experiment. Science 2014; 343: 263–68. Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneﬁciaries. Ann Emerg Med 2012; 60: 4–10. Baicker K, Taubman SL, Allen HL, et al, for the Oregon Health Study Group. The Oregon Experiment: eﬀects of Medicaid on clinical outcomes. N Engl J Med 2013; 368: 1713–22.
Cardiology: a call for papers Do you have a Late-Breaking Clinical Trial that will be presented at the American College of Cardiology meeting to be held on March 29–31, 2014 in Washington DC, USA? Have this rapidly reviewed with a view to coincident online publication and presentation at the meeting by submitting it as a Fast Track paper to The Lancet. The deadline for submissions is Feb 28, 2014.
www.thelancet.com Vol 383 February 15, 2014
Please submit via our online submission system EES, selecting Fast Track as the article type and stating in your covering letter that the submission is in response to this call for papers.
Published Online February 7, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60126-4 To submit a paper go to http:// ees.elsevier.com/thelancet
Stuart Spencer The Lancet, London NW1 7BY, UK