The Push to Expand Medicaid Ignores Reality of Poor Care

As noted previously, there is a concerted effort to expand Medicaid in Ohio and across the country.  This advocacy seeks to portray the Medicaid expansion as a “no-brainer” because the federal government pays for most of the cost and argues that if states don’t take this sweetheart deal millions will suffer.  But now expansion advocates have upped the ante, claiming thousands will die.

Put aside for the moment the budget questions (which are significant).  What is getting lost in this debate is the fact that Medicaid is not quality care.  What is being promoted is not lowering the cost of access to care but pushing people into a broken system that provides low quality care.

Our 2010 report Crushing Weight: National Health Care Law Threatens to Make Medicaid an Unsustainable Burden for Ohioans highlighted this problem:

The weight of the evidence suggests adults with Medicaid, the primary recipients gaining coverage through PPACA, have worse outcomes than privately insured individuals and oftentimes have worse outcomes than uninsured individuals, even after controlling for appropriate demographic and clinical factors .

One study found that Medicaid patients who suffered a heart attack were significantly less likely than patients with other forms of insurance to receive important clinical interventions.

Another found that Medicaid patients received fewer evidence-based therapies than patients with private insurance coverage .

The conclusion of another study was that individuals with Medicaid were more likely to experience complications and in-hospital mortality after surgery for colorectal cancer than both privately insured and uninsured patients.

Furthermore, a University of Virginia study of nearly 900,000 major operations in the United States found that surgical patients on Medicaid were 13 percent more likely to die in the hospital than uninsured individuals, controlling for demographic factors and health status .

The apparent inferiority of Medicaid suggests that increasing national enrollment by one third through PPACA will not lead to discernible health improvements.

But Avik Roy has a post which fully engages with the Harvard University study that is being cited by so many (see Columbus Dispatch and Innovation Ohio) in the ongoing push for Medicaid expansion.

As is so often the case, when you dig into the study things are less clear cut:

The authors looked at three states that expanded their Medicaid programs to childless adults—Maine, Arizona, and New York—and compared them to four neighboring states that did not—New Hampsire, Nevada and New Mexico, and Pennsylvania, over the years 1997 to 2007.

The authors found that Maine’s mortality rate increased relative to New Hampshire’s (by 13.4 deaths per 100,000); Arizona’s decreased relative to Nevada and New Mexico (by 10.2/100,000); and New York’s mortality rate declined relative to Pennsylvania (by 22.2/100,000).

In other words, the authors found that Medicaid was associated with an increase in mortality in Maine, but a decrease in mortality in Arizona and New York. Indeed, according to the authors, “single-state analyses showed [statistically] significant effects only in the largest state, New York.” Based on these three conflicting results, we are supposed to declare the debate over, and definitively conclude that Medicaid improves health outcomes?

Roy goes on to note how states and regions are very different and comparing them is not easy or always helpful, concluding:

In other words, the comparison that drove the authors’ key statistical finding, New York, was the one with the least suitable comparator state, and the most confounding problems.

But he ends with the point we started with, quality of care.

One thing that’s remarkable about the health outcome studies done by economists is that they almost never look at the outcomes of actual individual patients. The Harvard study used county-level data from the Centers for Disease Control, “totaling 68,012 observations specific to an age group, race, sex, year, and county.”

Contrast this approach to that of the landmark Medicaid outcomes study from the University of Virginia, which examined 893,658 individual surgical cases from the Nationwide Inpatient Sample database, and found that Medicaid’s health outcomes were worse than those of the uninsured. Which of these datasets would you consider to be more credible?

This gets to the fundamental problem in this debate.  Those pushing expansion are seeking to force low income people into a broken system instead of seeking to lower costs and increase access to private insurance which provides better quality of care.

Instead of doubling down on a failed program we should be focused on real reform that offers low income families access to quality care rather than force them into a government program with shrinking reimbursement rates, reduced access and lower quality of care.

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