Incentives and the Iron Law

  1. The Health Affairs blog entry about the Obamacare/opioid connection includes a link to this July public letter from Senator Ron Johnson to the Inspector General of HHS, arguing that the Medicaid expansion worsened the opioid crisis. The letter includes this simple HHS analysis confirming that overdose rates rose faster from 2013 to 2015 in Medicaid expansion states:

Overdose Deaths

Someone at HHS also had the bright idea of comparing similar expansion and non-expansion states:


I say “someone at HHS” produced this analysis because of Senator Johnson’s footnote referring to it: “HHS produced this document to me. It is unclear when HHS created this analysis. HHS staff insisted that HHS markings on the document be removed before producing it to me.”

This would imply that sometime after CDC Wonder figures from 2015 became available in late 2016, someone looked up the figures and concluded that Medicaid Expansion was making the opioid epidemic worse, and then someone else declined to publicize it until it was requested by Ron Johnson. You can imagine lots of good and bad reasons for doing this, but at a macro level, it shows a challenge with relying on federal research to evaluate public programs. In general, federal researchers have some advantages over academic researchers, in particular because (as Andrew Gelman recommends) data collection is often separated from analysis : the people collecting mortality data for the CDC or NAEP scores for the Department of Education are not the same people analyzing them down the line. Even when data collection and analysis are not completely independent, the study design and analytic approach is often relatively fixed beforehand for federal research (avoiding some of the Garden of Forking Paths that academic researchers like to stroll down). But there is still the problem of a lot of discretion of whether and when to publish unwanted results. I’ve heard, for example, that HHS sat on negative findings for Head Start and Early Head Start for years before finally releasing them. In the end, the Iron Law is the Iron Law– most federal programs won’t do much good, and some of them will do harm. But you have to trust the same agencies who administer programs and whose funding is structured around them to let it be known when they find out that they’re no good.

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