Conservatives believe Medicaid is worthless, so slashing it is harmless. They’re wrong.

How do Republicans justify the savage Medicaid cuts in their health care bills? By arguing that Medicaid is worthless.

Avik Roy, who has emerged as the chief defender of the Senate health bill, writes that “researchers have shown [Medicaid] has health outcomes no better than being uninsured.”

There are two things to say about this. The first is that it’s wrong. The second is that even if you believe it’s right, the Senate health bill is the opposite of how you would solve it.

Imagine you’re worried that Medicaid doesn’t do enough to improve the health outcomes of the poorest people in America. Perhaps you’d improve Medicaid, or give them money to purchase good private insurance. Or maybe you would plow money into a job guarantee or a direct cash transfer. What you wouldn’t do is take the money you’re spending on their health care now and redirect it into a capital gains tax cut for the rich.

Let’s begin with why this argument is wrong. These arguments are mainly referencing a study known as the Oregon Medicaid experiment. The study took advantage of a situation that reads like a dark satire of the American health care system: Oregon had money to expand Medicaid, but not enough money, so it held a lottery for poor people who needed health insurance. If you won the lottery, you got Medicaid; if you lost the lottery, you got nothing.

This created two similar groups that researchers could study: one that got Medicaid, and one that didn’t. The study only lasted two years, and it only included 10,000 people, so there is much it can’t tell us about the long-term effects of having health insurance. But what it found, in short, was that Medicaid protected enrollees from catastrophic health costs; boosted the likelihood of people reporting they were in good, very good, or excellent health by 25 percent; cut depressive symptoms by about 30 percent; and increased both diabetes diagnoses and treatment.

But the study also disappointed Medicaid’s backers: In particular, there was no evident improvement in blood sugar, blood pressure, or cholesterol levels after two years.

Some researchers have argued that the study didn’t have enough enrollees to measure those indicators. But even if you reject their arguments, it simply isn’t true that large increases in self-reported physical health and mental health, alongside better diabetes treatment and protection from financial ruin, is a state “no better than being uninsured.” (Self-reported health, by the way, is a powerful indicator of health outcomes: People who say they’re in “poor” health have a mortality rate between two and 10 times higher than those who say they’re in “excellent” health.)

But the Oregon study isn’t the only important study on the effects Medicaid has on health outcomes. Just ask the authors of the Oregon study. One of them, Kate Baicker, a Harvard health economist who served on George W. Bush’s Council of Economic Advisers, teamed up with fellow superstar health economist Ben Sommers and Atul Gawande (yes, that Atul Gawande) to assess the evidence of insurance expansions — particularly Medicaid expansions and the Massachusetts health reforms — on health. Their paper was published in the New England Journal of Medicine last week, and it’s worth reading in light of this debate.

The researchers assessed dozens of high-quality studies and returned an unequivocal result:

The body of evidence summarized here indicates that coverage expansions significantly increase patients’ access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery. These increases appear to produce significant, multifaceted, and nuanced benefits to health. Some benefits may manifest in earlier detection of disease, some in better medication adherence and management of chronic conditions, and some in the psychological well-being born of knowing one can afford care when one gets sick.

Such modest but cumulative changes — which one of us has called “the heroism of incremental care” — may not occur for everyone and may not happen quickly. But the evidence suggests that they do occur, and that some of these changes will ultimately help tens of thousands of people live longer lives. Conversely, the data suggest that policies that reduce coverage will produce significant harms to health, particularly among people with lower incomes and chronic conditions.

Take mortality, which the Oregon Medicaid study wasn’t big enough to measure:

One study compared three states implementing large Medicaid expansions in the early 2000s to neighboring states that didn’t expand Medicaid, finding a significant 6% decrease in mortality over 5 years of follow-up. A subsequent analysis showed the largest decreases were for deaths from “health-care–amenable” conditions such as heart disease, infections, and cancer, which are more plausibly affected by access to medical care.

Meanwhile, a study of Massachusetts’ 2006 reform found significant reductions in all-cause mortality and health-care–amenable mortality as compared with mortality in demographically similar counties nationally, particularly those with lower pre-expansion rates of insurance coverage. Overall, the study identified a “number needed to treat” of 830 adults gaining coverage to prevent one death a year. The comparable estimate in a more recent analysis of Medicaid’s mortality effects was one life saved for every 239 to 316 adults gaining coverage.

The authors estimate that expanding Medicaid saves lives at a cost of $327,000 to $867,000 per life saved. That might seem expensive, but it’s worth noting that “other public policies that reduce mortality have been found to average $7.6 million per life saved,” making Medicaid a comparative bargain.

Nor are lives saved the only measure by which health insurance improves well-being. The security that you can afford medical treatment when you or your family needs it is a huge relief. One reason Medicaid expansions seem to have such a profound effect on psychological well-being is that they lift an elemental fear that hangs over daily life.

This is probably part of the reason Medicaid enrollees really, really like Medicaid. A 2015 Gallup poll found that 75 percent of Medicaid enrollees were satisfied with the system — a satisfaction rate that bested enrollees in employer-sponsored insurance.

One limitation to these studies is that even the longest of them only stretch over five or so years. We don’t have studies measuring the effect of consistent health insurance over 10 or 20 or 30 years. We don’t know how many lives that kind of access to the medical system saves, nor how much disability it prevents, nor how much pain it eases, nor how much psychological comfort it offers. But the patients who qualify for Medicaid expansions are the patients least likely to have regular, long-term health insurance in the absence of Medicaid coverage, and so they’re the patients most likely to benefit from the payoffs of consistency, whatever those payoffs might be.

One final point here. All studies of Medicaid expansions — including the Oregon experiment — show that Medicaid works perfectly well as insurance; beneficiaries are able to go the doctor and get screened for diseases and afford treatment. Surveys show the same thing: a Morning Consult poll commissioned by AHIP found 83 percent of Medicaid beneficiaries are satisfied with their access to doctors, for instance. To believe that none of this has an effect on health is to believe that medical care itself fails to improve health.

I’m very sympathetic to arguments that medical care is overvalued, and that in practice, it does less good than we hope. Many of the treatments we receive are poorly studied, there’s evidence that doctors routinely violate best-practice standards of care, and we know that patients follow medical advice inconsistently (Shannon Brownlee’s book Overtreated is an excellent look at these issues). But these dynamics affect all of us — Medicaid is just better studied than other forms of insurance coverage — and the proper response to these arguments is to do a better job assessing which medical treatments work and which don’t, not to simply take health insurance away from poor people.

Imagine you don’t believe any of the evidence in the preceding section. Let’s say you still think Medicaid is worthless program that is no better for its beneficiaries than nothing at all. Then what?

Well, perhaps you would want to restructure Medicaid so it worked better, or give the poor enough money to buy equivalent forms of private insurance. Perhaps you would take seriously the literature suggesting health insurance is a secondary determinant of health outcomes, and you would use the money to finance wage subsidies and job guarantees for the poor, or a basic income of some kind. Maybe you would decide that a healthy environment matters above all and you would propose taking the money we spend on Medicaid and using it to remove lead from low-income communities and subsidize safer, cleaner transportation and housing options.

What you wouldn’t do is what the Better Care Reconciliation Act does: offer people making below-poverty wages insurance plans with $6,000 deductibles — insurance that is too expensive for them to actually use — while plowing the savings into a large capital gains tax cut for the richest Americans.

The BCRA “represents the biggest potential redistribution from lower- and moderate-income people to the wealthy of any legislation in modern U.S. history,” write Jacob Leibenluft and Aviva Aron-Dine of the Center on Budget and Policy Priorities. There is no plausible theory under which that’s the best way to improve heath outcomes for the poorest Americans.

This is where the attacks on Medicaid — no matter what you believe about Medicaid itself — completely fall apart as a justification for the Senate GOP’s health bill. “Paying for a massive tax cut for the wealthy with cuts to health care for the most vulnerable Americans is morally reprehensible,” writes Marc Thiessen, the former George W. Bush speechwriter. A conversation about how to best use the money we’re currently spending on Medicaid to improve health outcomes for the poor would be a worthwhile conversation to have. But that’s not the conversation we’re having.

Correction: Originally, this piece quoted Oren Cass, a senior fellow at the Manhattan Institute. Cass wrote an influential piece arguing, among other things, that:

Researchers have found that Medicaid patients with a variety of conditions and medical needs experience worse outcomes than similar uninsured patients. In a randomized trial in Oregon that gave some individuals Medicaid while leaving others uninsured, recipients gained no statistically significant improvement in physical health after two years.

As this piece argues, I disagree with Cass’s conclusions on whether Medicaid improves health, and with his framing of the Oregon study. But over email, Cass clarified his broader position, which is that Medicaid isn’t worth much, but it’s also not worthless:

I have never called Medicaid worthless and shifting resources to better uses like a wage subsidy is precisely my position. I have written “I think conservatives make a mistake using such studies to argue Medicaid is effectively worthless, for two reasons. First, because Medicaid is not worthless. It might produce an atrociously low return on spending, it might achieve nothing for a significant share of recipients, but there are also cases where it helps. Indeed, most people probably know someone who has at some point benefited from access to Medicaid coverage. Studies will undoubtedly emerge that identify positive effects.”

Given that, I’ve removed Cass’s comments from the lede, as it’s not fair to frame him as someone who thinks Medicaid is worthless. I also asked Cass if he supports or opposes the BCRA. He said he opposes the bill because of its individual market provisions. He said he would support the proposed block grant for Medicaid, but would prefer one in which “a significant share of the savings were allocated to other anti-poverty strategies.”