Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.
It’s worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that.
I have written before about the use of premiums in Medicaid programs across the United States. But a new study in Pediatrics collects the evidence, and it’s worth a look. “Medicaid and CHIP Premiums and Access to Care: A Systematic Review“. This is Healthcare Triage News.
For those of you who want to read more:
- Medicaid Gives the Poor a Reason to Say No Thanks
- Medicaid and CHIP Premiums and Access to Care: A Systematic Review
I have written before about the use of premiums in Medicaid programs across the United States. But a new study in Pediatrics collects the evidence, and it’s worth a look. “Medicaid and CHIP Premiums and Access to Care: A Systematic Review”.
Go read my latest post over at the AcademyHealth blog!
One common argument from opponents of the Affordable Care Act is that an expansion of government into health care will result in “crowd out”, where private influences and coverage go down as public ones go up.
But that’s not always the case, as seen in a study just released by the NEJM (Full disclosure, I’m one of the authors of this work). “Dependent Coverage under the ACA and Medicaid Coverage for Childbirth.”
Go read it. And read more by me about it over at the AcademyHealth blog!
We spend a lot of time discussing health care spending for adults, especially the elderly. Some argue that’s because we spend the majority of money on those populations. But as a pediatrician, parent, and health services researcher, I sometimes get annoyed at our lack of attention to children. Luckily, I subscribe to some journals that focus on children. From Pediatrics, “Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance“:
Go read about this paper, and how it fits into what we know about Medicaid spending in my latest post over at the AcademyHealth blog!
I have high regard for Nicholas Bagley. So when he sends me something with an endorsement, I pay attention. Today, he sent me a link to a paper on Medcaid and Medicaid expansion by Mark Hall, which includes this passage:
Some conservative policy advocates claim either that people are worse off being on Medicaid than being uninsured, or that they would be substantially better off if the government fundamentally restructured Medicaid or replaced it with an entirely different program. The implausible (if not preposterous) argument that people are worse off with Medicaid than with nothing at all rests on a handful of studies reporting that Medicaid patients do worse in some particular medical settings than do uninsured patients. Highly regarded health economist Austin Frakt has thoroughly and convincingly debunked these studies, and this entire line of argument, as follows.
Frakt explains that observational studies that compare uninsured people with those covered by Medicaid are completely inadequate for drawing conclusions about whether Medicaid coverage causes worse health. This is because people do not sort themselves randomly between insurance conditions. All else being equal, sick people are more likely to seek out insurance, including Medicaid. As a result, uninsured people are, in general, substantially healthier than people with Medicaid. Therefore, it is almost certainly spurious to conclude that Medicaid is the cause of the worse health observed in those whom it covers.
I’m flattered. Nick has high regard for Mark, as do I, writing me that he thinks he’s “among the best health law scholars in the country, if not the very best.”
The work Mark cites by me is coauthored by Aaron, Harold Pollack, and Uwe Reinhardt, all highly regarded as well. Click through for the details. It appears to have been published in 2014, but I don’t recall having seen it.
Harold Pollack, Timothy Jost, and I have a piece in The American Prospect about why we need Medicaid and how we should improve it.
We discuss an important NBER paper by Amy Finkelstein and her colleagues that tried to measure how much Medicaid is worth to those who receive it. The authors used data from the Oregon Health Insurance Experiment. The headline findings were that
- Uninsured people who get Medicaid only gained from 20 to 40 cents in value from each dollar spent by the government.
- A principal reason why the benefit of getting insured was so small is that when uninsured people received care, they typically paid only 20 cents on the dollar for those services. Safety-net providers, state or local government, friends, relatives, or someone else absorbed the remaining costs.
- Because a large fraction of Medicaid expenditures financed care that recipients would have received anyway (for example, by leaving bad debt at hospitals), it is unclear whether recipients themselves would have been willing to pay the full costs of Medicaid.
Finkelstein and her colleagues were careful not to draw normative conclusions from these findings. But some Medicaid critics have argued, first, that Medicaid is an inefficient way to benefit the poor. If a Medicaid dollar results in only 20 cents in benefit to a previously uninsured person, wouldn’t it be more efficient to simply give that person a dollar? And, second, Medicaid is actually a subsidy for people other than those it ostensibly helps.
We see matters differently. One important reason why the value of Medicaid appears to be so low is that Finkelstein put a much lower value on the health of Medicaid recipients than is typically used in valuations of the health of other Americans. We also argue that in many cases, we should not be troubled that Medicaid payments are going to third parties who are, after all, providing care to Medicaid recipients.
Please read the whole thing.
Alaska has accepted the Medicaid expansion:
After failing to persuade his Legislature to expand Medicaid, Gov. Bill Walker of Alaska said Thursday that he planned to unilaterally accept the federal funds available to cover more low-income residents under the program.
Mr. Walker, an independent who took office in December, said in a news conference in Anchorage that he could not wait any longer to offer health coverage to the roughly 42,000 people his administration projects will be eligible under the expansion. Expanding Medicaid — an option for every state under President Obama’s Affordable Care Act — was a campaign priority for Mr. Walker, who couched it as a “common-sense decision” for the state’s economy and for the health of its people.
Evidently Governor Walker tried to get the legislature to support the expansion, but when those options failed, he used his power of office to do it himself. From the tone of the articles I’ve read, he appears to be acting legally. At least, I’m not seeing any legislators calling him a tyrant and threatening lawsuits.
That makes Alaska the 30th state to accept the Medicaid expansion. Many of my colleagues think that is a sign of how weakly the ACA has been implemented. Me? I think the opposite. Healthcare reform is a marathon, not a sprint. It’s important to remember that the Medicaid expansion only went into effect less than two years ago. It’s really young. Traditional Medicaid was passed in 1965, and the last state to accept it (Arizona) did so in 1982. If that same gap held true for the ACA, then we should expect the last state to accept the expansion in 2031.
Even if you accept Arizona as an outlier, all states but that one didn’t start participating in Medicaid until 1972, seven years after it began. That would be 2021 for the Medicaid expansion.
And for anyone who thinks comparing something to Medicaid is a bad example, because Medicaid isn’t as “beloved” as Medicare, remember that just a few years ago the Supreme Court ruled that traditional Medicaid was so American-as-apple-pie and essential-to-freedom that threatening to take it away from a state was unconstitutional coercion.
Healthcare reform is a long-haul process. I know many people wish that every state would just accept the Medicaid expansion right now, but that’s unlikely to happen. The good news for them is that the fact that all the states haven’t come on board yet doesn’t mean they won’t in the near future.
I have obviously touched a nerve in many TIE readers. So let’s take a step back and revisit what I wrote and what is going on here.
There were some studies that made predictions about the health and composition of the newly eligible for Medicaid. Those studies could be interpreted to mean the Medicaid expansion would cost less than predicted, because people entering would be healthier than those already enrolled. I WAS ONE OF THE PEOPLE WHO THOUGHT THAT INTERPRETATION MIGHT BE POSSIBLE. A recent report from CMS suggests that this lower-than-expected expense didn’t happen. I wrote that we need to figure out why and keep watching.
None of this was to suggest that the prior research was incorrect or poorly performed. It appears, upon further looking at the report, that there are some reasons that the differences are higher than estimated:
There are several explanations for the difference between the estimates in this year’s report and those in previous reports. First, most of the States that implemented the eligibility expansion are covering newly eligible adults in Medicaid managed care programs, and on average the capitation rates for the newly eligible adult enrollees were significantly greater than the projected average costs previously calculated.
Austin flagged this, by the way. In fact, some of the capitation rates may have been raised because states predicted pent-up demand because they assumed people entering might be sicker (in spite of the research I talked about).
And there’s this:
Data for newly eligible adults are still limited. While CMS has reported some enrollment and expenditure data for this group, data on claims and managed care encounters, along with data on the health status and demographics of these enrollees, are not yet available. Thus, there is still considerable uncertainty about the health care costs of newly eligible adults in 2014, as well as for future years.
Medicaid still expects newly eligible adults to cost less in the future (Figure 6). It’s entirely possible they are correct.
But here’s the thing. It may be that this research turns out to be incorrect. I doubt it, in that I think the work is correct in that the newly eligible appear to be less sick than those already covered. It may be that this research is correct, and that still spending goes up for other reasons. Maybe people just spend more. Maybe docs find new ways to bill more. Maybe policy makers set capitation rates too high.* But if I report on research, and make some guesses as to the future, and they turn out to be incorrect, I will write that my predictions were wrong, that we need to figure out why, and that we should keep looking into it.
That’s what I did. That’s what I will continue to do.
*This appears to be the best hope for an answer right now – but we have to make sure.
the battle to set in place a health care system that works for all Americans is far from over.
Cannon is absolutely right.
King was a victory because it prevented millions of people from losing insurance coverage. But it did not advance the cause of health care reform a centimeter with respect to the status quo ante King.
In The New Republic, I argue that the principal goals of health care reform remain to be fulfilled. Getting them fulfilled will require us to win new political fights to extend universal health insurance in every state. We need to keep working on innovative health care delivery models that control the growth in health care expenditures while improving the quality of care.
Above all, we need to get more empirical:
Health care reform has to be driven by results, not political beliefs. Programs should be selected based on evidence, such as the results of randomized clinical trials. Every new reform should collect rigorous data to determine whether it works.