A new study in JAMA Internal Medicine examines variation in access to primary care by insurance status (Medicaid, private, and uninsured). An Urban Institute study by some of the same authors offers complementary evidence. For a more complete view of “access,” both are worth understanding. I summarize the JAMA IM study in an AcademyHealth post today, and will comment on the Urban Institute one later this week.
Austin and I have covered this topic a number of times, but new research reinforces it. I cover that work in my latest post over at the AcademyHealth blog.
I recently discussed how the expansion of Medicaid through the ACA may benefit people living with HIV/AIDS. Specifically, getting insurance may encourage previously uninsured people at risk to get tested. Some of them will discover that they are HIV+, enabling them to benefit from early combined antiretroviral treatment (cART). If so, they will not only greatly extend their own lives, but also prevent significant numbers of fresh HIV infections, because cART radically reduces the probability of sexual transmission of HIV.
This is a plausible argument for one benefit of expanding Medicaid. But plausible arguments are one thing, confirmatory data are another. A critic can and should ask: If expanding Medicaid really saves lives, why don’t we have data supporting a strong mortality benefit for people receiving Medicaid versus being uninsured?
Chris Conover has a thoughtful post on just this question. He makes two valuable points. First, he questions some previous research that purported to show a large mortality cost of being uninsured. Second, he poses a nifty thought experiment designed to raise questions about whether expanding Medicaid is a cost-effective way to increase life expectancy.
Conover begins by reviewing some claims for dramatic mortality benefits associated with becoming insured, based on observational studies (such as this one). He demolishes these claims, for reasons that are worth quoting.
All are so-called observational studies meaning that the two groups being compared (uninsured and privately insured) each self-selected itself into the group. Many uninsured admittedly are in that group because they lack the means to pay for coverage, but the key point here is that unlike a randomized controlled trial, in which people are randomly assigned to be in either the “treatment” group or “control” group, there is no reason to suppose that the characteristics of the two groups will be comparable.
This argument also demolishes the commonly heard claim that Medicaid is harmful compared to being uninsured. This claim is similarly based on observational studies that are methodologically weak for causal inference purposes, studies that Conover sensibly ignores.
Unfortunately, Conover does not discuss the most relevant scientific studies on the effects of getting health insurance (like this one). This is the instrumental variables literature, summarized by Austin here. In these studies, researchers look at ‘experiments of nature,’ where large groups of people received or did not receive Medicaid for arbitrary reasons that mimic random assignment. Austin:
My take-away from the Medicaid-[Instrumental Variable] literature review is: there is no credible evidence that Medicaid results in worse or equivalent health outcomes as being uninsured. […] [It] strongly suggests Medicaid is better for health than no insurance at all.
This conclusion was reprised in the NEJM by Austin, Aaron, Harold Pollack, and Uwe Reinhardt.
So what’s my bottom line on the mortality benefit of Medicaid? Getting Medicaid will likely give the average uninsured person at best a small mortality benefit, albeit of uncertain amount. It likely gives the small group of uninsured people with dire health conditions — e.g., people living with HIV/AIDS — a larger benefit. (And, although this is a different question, we could build a better insurance program for the poor than Medicaid, and it would likely have a better effect.)
Conover, however, then poses a challenge to people who hold views like mine. He notes that there are preventive health interventions targeting smokers that would save lives with greater certainty than expanding Medicaid. So if we are interested in reducing mortality — and if the health benefit of Medicaid is likely small — then is increasing Medicaid the most cost-effective way to improve longevity?
It would be uncharitable to read Conover as literally proposing to repeal the Medicaid expansion and instead invest billions of dollars in preventive health care. This is, instead, a worthwhile thought experiment. Conover wants people who defend the Medicaid expansion to explain why given the small (possibly negligible in his view, but not mine) and uncertain (his view and mine) mortality benefit.
I have no trouble defending the expansion, in part because I have no need to do so on mortality benefits alone. Insurance has financial and quality of life benefits over and above its effect on mortality. And even though it may have only a small mortality benefit for the average uninsured person, it will mean life or death for others, and those people matter. For these reasons, people across the world view access to health care for all citizens as a matter of justice.
Moreover, I do not attribute the small benefit of Medicaid primarily to the deficiencies of that scheme for financing health care. Remember, what insurance does for health is to provide access to health care. My view is that the effect of insurance is much smaller than it should be, given the money that we spend on it, because the effect of accessing health care is much smaller than it should be, given the money that we spend on it. Universal access to health care is a solvable problem: check almost any developed country. Conover’s thought experiment ought to shock us into asking the harder and deeper question: “Why doesn’t our health care system give the poor and rich alike better value for our health care dollars?”
That question has many answers. Here are a few: We don’t pay enough attention to the social determinants of health. We don’t work hard enough to fix the manifold deficiencies in the quality of health care. We miss opportunities for cost-effective prevention. We don’t follow patients effectively, to support them in adhering to their treatments. And we don’t invest enough in medical research to achieve fundamental advances both in treatments and in how to deliver them.
Perhaps Conover sees the matter differently. Nevertheless, I urge you to think through the point highlighted by his thought experiment, that extending health insurance has only a small and uncertain effect on mortality. One thing that I hope we can all agree on is that our reaction to the literature on the effect of Medicaid on health should be: We can do better.
I’d love to go ahead the just repost his entire piece here, but I doubt the NEJM would like that. Instead, I really, really encourage you to go read it and then come back here:
By voting repeatedly to repeal the Affordable Care Act (ACA) over the past 4 years, Republicans have risked being identified as a party without a positive health policy agenda. On January 27, 2014, however, three Republican senators — Orrin Hatch (UT), Tom Coburn (OK), and Richard Burr (NC) — unveiled a proposal that would not only repeal the ACA, but also replace it with comprehensive legislation based on Republican health policy principles.1 Although the proposal recycles long-standing Republican prescriptions, it also offers new ideas.
The proposal would not entirely repeal the ACA. Republicans seem to be coming to terms with the fact that the ACA has permanently changed the health policy landscape. The proposal would, for example, retain the ACA’s Medicare provisions in recognition, no doubt, of the difficulty of rolling back all the ACA’s provider-payment changes or reopening the doughnut hole in Part D coverage of prescription drugs but also apparently in order to use the ACA’s $700 billion in Medicare payment cuts to finance Republican initiatives. The proposed legislation would retain popular ACA insurance reforms, including the ban on lifetime insurance limits, required coverage for children up to 26 years of age on their parents’ policies, mandated disclosure of insurance benefits and limitations, and a ban on canceling an enrollee’s insurance policy except in the case of fraud. It would retain limits on age rating of insurance premiums, but insurers could charge five times as much for an older as for a younger enrollee, as opposed to the three-to-one ratio limit in the ACA.
I only have time for some high level thoughts this morning, but here they are:
They go with a tax credit, much like the ACA, to help people buy insurance. That’s fine. But it would be set against the cost of high-deductible coverage, which would drive most of the poorer Americans into coverage where they would still have significant out-of-pocket costs. That’s not as fine.
They keep people who maintain “continuous coverage” protected from medical underwriting. In other words, they get the community ratings that makes coverage affordable for people who are sick. But I still don’t understand what they would do for people who get sick, lose their jobs, and can then no longer afford their insurance.
They completely eliminate the limits on out-of-pocket costs. This could be a real issue if you get really sick.
They are pushing for Medicaid to be a block grant program. We have talked about our concerns with this many times. They also want to bring back Medicaid health opportunity accounts. Jost points to South Carolina, where they failed miserably. I think supporters would likely redirect him back to the Healthy Indiana Program, where far more people signed up.
Finally, there is the cap on the health insurance tax exclusion. I think most economists, including those here, would support this. Currently this exclusion favors the rich and distorts the market. But this would be even more disruptive to the employer-based market than the ACA, and I can’t see them keeping this in the proposal as is.
There’s more in Jost’s piece. Go read it!
The following is co-authored by Aaron and Austin.
They just won’t die. Evidently, the House Republican budget is going to take another whack at Medicaid reform. Today, from the WaPo:
Medicaid, which provides health coverage to low-income families, is the object of a sharply worded review. “Medicaid coverage has little effect on patients’ health,” the report says, adding that it imposes an “implicit tax on beneficiaries,” “crowds out private insurance” and “increases the likelihood of receiving welfare benefits.”
There are studies documenting circumstances under which Medicaid can substantially “crowd out” private insurance. But, as has been explained on TIE, those circumstances don’t necessarily apply to the ACA. Moreover, many people at the low end of the socio-economic spectrum have the option of Medicaid or nothing. They make less than 138% of the poverty line. They aren’t able to afford insurance without massive subsidies.
But, as always, we want to focus on the first statement, the one that declares that Medicaid doesn’t improve patients’ health. That’s not true.
Does anyone really dispute that having health insurance is better than not having health insurance? Anyone who does should put their money where their mouth is. Mediaid isn’t welfare. You don’t get cash. It pays for health care if you need it. And, like all health insurance, it makes people healthier and saves lives. Lots of people say so. Studies confirm this.
That research could be improved with the use of better research design, and methodologically stronger studies have shown that Medicaid is good for HIV mortality, child health, infant mortality, and more.
Which brings us to the Oregon Health Study, an actual randomized controlled trial of Medicaid. We have both written on early results. We’ve also commented on the later results, which are the ones people often seize upon to discredit Medicaid. Again.
People say that it does little to improve the health of people who have diabetes, who are at risk for heart disease, who have high cholesterol, or who have high blood pressure. There are real problems with those assertions. The Oregon study was not powered to detect improvements in those domains. We’re sorry, but it wasn’t. Here’s Austin explaining how it wasn’t set up to detect major changes in cholesterol or the Framingham Risk Score. Here’s Aaron talking about how it couldn’t detect changes in hypertension because the vast majority of people didn’t have it, and the assumptions that underlie arguments for being able to see a change aren’t on point. Same goes for diabetes.
Here’s a summary of those issues.
Why do people have insurance? Most people have it to protect themselves from financial ruin should they get really ill. But they also get it because it provides them the ability and incentive to get health care if they need it. Medicaid is about access. It’s just the first step in the chain of events that leads to better health and wellbeing. It’s not sufficient, but it is often necessary.
Many who argue that insurance should immediately and significantly make a population healthier are glossing over these other issues. They also seem not to care that there are no good RCTs proving that private insurance (or Medicare) do this.
There are lots of legitimate claims to make against Medicaid. It under-reimburses physicians, for instance, causing access problems in some areas and for some beneficiaries. (Guess what. Those problems are even worse for the uninsured, though.) But the natural response to saying docs don’t get paid enough would be to increase Medicaid funding to improve that. Gutting the program will do the opposite.
We look forward to a continuing and lively debate on how to reform the health care system. But declaring that health insurance in the form of Medicaid hurts people or “doesn’t work” ignores the real good that it does for so many people. (And, come on, health insurance is just pushing money around—it isn’t medicine or procedures.) Let’s listen to each other’s arguments and respond to them, instead of repeating talking points past each other.
From Health Affairs, “New Medicaid Enrollees In Oregon Report Health Care Successes And Challenges“:
Medicaid expansions will soon cover millions of new enrollees, but insurance alone may not ensure that they receive high-quality care. This study examines health care interactions and the health perceptions of an Oregon cohort three years after they gained Medicaid coverage. During in-depth qualitative interviews, 120 enrollees reported a wide range of interactions with the health care system. Forty percent of the new enrollees sought care infrequently because they were confused about coverage, faced access barriers, had bad interactions with providers, or felt that care was unnecessary. For the 60 percent who had multiple health care interactions, continuity and ease of the provider-patient relationship were critical to improved health. Some newly insured Medicaid enrollees recounted rapid improvements in health. However, most reported that gains came after months or years of working closely and systematically with a provider. Our findings suggest that improving communication with beneficiaries and increasing the availability of coordinated care across settings could reduce the barriers that new enrollees are likely to face.
There are some who hate Medicaid so much that they will actually argue that giving it to poor sick people will harm them more than it will help them. There are some who will point to the fact that since the Oregon Medicaid Study failed to show massive improvements in hypertension or diabetes, that it’s a failed program. Never mind that it was underpowered to do so. Or that we’ve never really held private insurance or Medicare to this standard.
But there are also some who think that providing access is all that matters. Give people insurance, even Medicaid, and all will be well.
Access is necessary, but not sufficient. Improvements to delivery are also needed. Those are, in many ways, harder. But they’re needed.
Because one fifth of veterans had enrolled in VA coverage, it is worth noting that about 16% of them will also likely be eligible for the Medicaid expansion and all will also be eligible to participate in the health insurance exchanges. Although what proportion of VA service users will enroll in other health coverage plans is unknown, dual or multiple enrollment may have its benefits and problems. Although it may increase health care access and options for veterans, it may also lead to more fragmented, lower quality care. These are important issues for the VA to plan for and possibly preempt.
Just flagging in case you’re looking for further reading.
The Affordable Care Act expanded Medicaid eligibility, at least in the states that did not refuse it. But being covered by Medicaid will not get you access to healthcare unless the people providing the health service that you need accept Medicaid.
Janet Cummings, Hefei Wen, Michelle Ko, and Ben Druss looked at whether US counties had a substance use treatment facility that accepted Medicaid. Substance use disorder (SUD) is more common among the poor and treatment is expensive. Hence for many poor people, Medicaid coverage is essential for getting access to care.
Cummings et al. found that in large areas of the US, there are no SUD treatment facilities that accept Medicaid. The goldenrod counties in the Figure below have no outpatient treatment facility.
Forty percent of counties in the US do not have an SUD treatment facility that provides outpatient care and accepts Medicaid. Counties in rural areas are much more likely to lack access to outpatient SUD facilities that accept Medicaid, particularly those in Southern and Midwestern states. Our findings also indicate that gaps in the SUD treatment infrastructure are further compounded for areas with a higher proportion of racial and ethnic minorities.
Cummings and her colleagues found that counties with a higher percentage of Black citizens were substantially less likely (odds ratio = -3.1) to have a substance use facility that accepts Medicaid, even when you statistically control for the population density, poverty, and rural geography of the county. There is, therefore, de facto racial discrimination in access to substance use care for poor people.
It is not clear why some states lack SUD treatment facilities that accept Medicaid. Most counties in Texas and Nevada are sparsely populated, which might explain the lack of facilities. But so are large sections of Arizona, New Mexico, and Utah, and these states are much better served. It is possible that there are problems with Medicaid — for example, how much it pays for care — that discourage providers from opening treatment centers. But why are those problems with Medicaid so much worse in counties with lots of Black citizens? Why do those problems suddenly get worse at the New Mexico / Texas border?
The literature on access problems for Medicaid recipients is mixed, in part because of wide variation in the extent to which providers accept Medicaid payment (see here, here and here). However, Cummings’ data suggest that expanding Medicaid will not be sufficient to get poor people access to SUD care in many states. We may need to overhaul Medicaid, or replace it with a better system for insuring the poor. But there are also some states that need to ask themselves why they are failing to provide access to SUD care for their poorest residents.
Though the Affordable Care Act (ACA) does not directly change the Veterans Health Administration (hereafter, VA), veterans are an important subgroup of those affected by the law. Find out why and how in my latest post on the AcademyHealth blog.