Abstract: Academic literature has consistently illustrated
that Medicaid patients—adults and children—have inferior access to
health care, and notably poorer health outcomes, than privately insured
patients. Due to the program's low reimbursement rates, more and more
doctors are refusing to even accept Medicaid. As a result, it is
becoming increasingly difficult for Medicaid patients to find access to
primary and specialty care physicians. When Medicaid patients are
admitted to hospitals, they are often admitted with more serious
conditions than those with private insurance. By further expanding this
broken program, Obamacare will only exacerbate the situation, continuing
to harm many low-income Americans who have no option other than
Medicaid. Policymakers should reform Medicaid to allow Medicaid patients
access to private insurance in a consumer-driven market.
Established as a fundamental component of President Lyndon Johnson's
Great Society, Medicaid is a jointly funded federal and state program
that pays for health care for low-income individuals. The academic
literature has consistently illustrated that Medicaid patients have
poorer access to care, and poorer health outcomes, than privately
insured patients. By further expanding this broken program, the Patient
Protection and Affordable Care Act - Obamacare - only exacerbates the
situation. Policymakers should reform Medicaid to provide consumers with
greater access to private insurance in a consumer-driven market.
Medicaid typically pays physicians 56 percent of the amount that private insurers pay.
[1] Given these low reimbursement rates, more and more doctors are refusing to accept Medicaid.
[2]
As a result, it is becoming increasingly difficult for Medicaid
patients to find primary care doctors and specialists. When Medicaid
patients are admitted to hospitals, they are often admitted with more
serious conditions, and in some cases, with a higher level of
co-morbidity, than privately insured patients. The peer-reviewed
academic literature clearly illustrates Medicaid's problems for children
as well as for adults.
Children Suffer Under Medicaid
Medicaid undermines care for millions of children. Consider, for
example, children with asthma, one of the most common chronic diseases
affecting children in the United States. A 2001 study published in the
Journal of Health Care for the Poor and Underserved
compares hospital care for children with asthma who are covered by
Medicaid to children with asthma who are covered by private insurance in
California, Georgia, and Michigan.
[3]
The authors found slightly longer length of stay and significantly
poorer outpatient care for the children on Medicaid. In terms of
outpatient care, the authors specifically found that pediatric Medicaid
patients were more likely than privately insured patients to be
discharged on subpar medication routines. The authors also found that
Medicaid patients generally lacked a consistent source of outpatient
care, unlike privately insured patients. These issues with outpatient
care suggest that these children are more likely to be re-admitted for
hospitalization at a subsequent time in the future.
Adequate access to care is also a serious problem for children on Medicaid. A 2004 study published in
Pediatrics examined children’s access to specialty surgeons in Southern California.
[4]
The researchers surveyed specialty surgeons throughout southern
California and found that the surgeons are generally less inclined to
accept patients enrolled in Medi-Cal (California’s version of the
Medicaid program). The surgeons cited difficult paperwork,
administrative burdens, and poor reimbursement rates as reasons for not
wanting to take on these patients. The authors consequently caution
policymakers about expanding this program, noting that coverage through
Medi-Cal does not necessarily signify meaningful access to health care.
The authors also suggest that expanding Medi-Cal may in fact exacerbate
the existing problems of limited access to care.
Another study published in 2005 in
Urology found similar problems with boys’ access to urologic care.
[5]
The authors surveyed a simple random sample of urologic offices located
throughout California in order to determine the offices’ attitudes
toward Medi-Cal recipients. Of the offices they found that were willing
to see pediatric patients, the authors found that 96 percent of these
offices would accept privately insured patients. They also found that
only 41 percent of these offices would accept Medi-Cal patients.
Three-quarters of the offices that refused to accept Medi-Cal patients
were unable to even recommend offices that would.
Furthermore, a recent study published in the
New England Journal of Medicine examined pediatric access to specialty clinics in Cook County, Illinois.
[6]
Sending out research assistants posing as mothers and making phone
calls to a random sample of specialty clinics, the study found a
significant disparity between access to specialty care for privately
insured children and children on Medicaid as well as the publicly funded
Children’s Health Insurance Program (CHIP). Specifically, the
researchers noted more denials of appointments as well as longer waiting
times for Medicaid and CHIP patients than for privately insured
patients.
These studies suggest that children on Medicaid lack access to the
kind of care that privately insured patients enjoy. As long as the
program in its current form remains in place, these problems will
persist.
Adults Suffer Under Medicaid
Children are not the only ones Medicaid is failing. A number of
academic studies have also pointed out the disparities in health
outcomes between adult Medicaid recipients and those who are privately
insured.
A 1993 study published in the
New England Journal of Medicine
found that breast cancer patients in New Jersey were often diagnosed
with more advanced stages of the disease and had higher risks of death
if they received their insurance coverage through Medicaid instead of
private insurance.
[7] These findings have been corroborated by a number of subsequent studies looking at a variety of serious illnesses:
- A 2000 study published in Cancer examined health outcomes of
breast cancer patients in Florida. The study found that, as a result of
later diagnoses, Medicaid patients have higher mortality rates than
patients who are covered by commercial fee-for-service insurance.[8]
- A 2000 study published in the American Journal of Public Health
that examines colorectal cancer treatments and outcomes found that
Medicaid patients not only had higher mortality rates, but were also
less likely to receive cancer-directed surgery, than patients using
commercial fee-for-service insurance.[9]
- A 2001 study published in Cancer compared health outcomes
for a variety of cancers for patients in Michigan. The study found that
Medicaid patients had significantly higher rates of occurrence as well
as higher risks of death for breast, cervix, colon, and lung cancers
compared to non-Medicaid patients. The study also found that Medicaid
patients had a higher risk of being diagnosed with these cancers at
later stages.[10]
- A 2003 study published in the Archives of Internal Medicine
that compares health outcomes for colorectal, lung, prostate, and
breast cancer in Kentucky for a variety of insurance classifications
also found similar results. For all four illnesses, the authors found
that survival rates are markedly higher for privately insured patients
than for Medicaid patients.[11]
Most recently, a 2010 study in the
Journal of Hospital Medicine
found similar results for non-cancer-related illness. In this study,
the authors examine the relationship between insurance status and health
outcomes for myocardial infarction, stroke, and pneumonia patients.
[12]
The authors statistically analyzed a nationally representative hospital
database and noticed, even after adjusting for factors such as age,
gender, income, other illnesses, and severity, higher in-hospital
mortality rates for Medicaid patients than for privately insured
patients. Additionally, even after adjusting for these factors, the
study found that Medicaid patients hospitalized for strokes and
pneumonia also ran up higher costs than the privately insured, as well
as the uninsured.
Medicaid: Hinders Access to Care, Fails to Meet Patients’ Needs
A number of academic studies over the years have illustrated that
Medicaid patients have consistently had poor access to care and that
Medicaid fails to meet important needs:
- A 1992 study in the Journal of the American Medical Association examined hospitalizations in Massachusetts and Maryland.[13]
The study found that Medicaid and uninsured patients were statistically
more likely than privately insured patients to be hospitalized for
avoidable conditions such as pneumonia and diabetes.
- A 2007 study in Health Affairs examined access to specialty services for patients who receive primary care from community health centers.[14]
The study found that Medicaid recipients have significantly more
difficulty accessing specialty care than privately insured patients.
- A 2012 study in Health Affairs examined physicians’
willingness to accept new patients. Using survey data from a nationally
representative sample, the study found that nearly one-third of
physicians nationwide will not accept new Medicaid patients. Doctors in
smaller practices, as well as doctors in metropolitan areas, are among
the least inclined to accept new Medicaid patients.[15] The authors’ results suggest that this reluctance may largely be a consequence of Medicaid’s poor payment rates to doctors.
Given these findings in the peer-reviewed literature, it is not
surprising that Medicaid patients often arrive at emergency rooms in
poor, and in many cases, untreatable condition. In fact, research has
shown that Medicaid and CHIP patients end up in emergency rooms even
more frequently than uninsured patients.
[16]
Solutions
As the academic research has consistently suggested, Medicaid’s
so-called safety net cripples the very people it is designed to help. To
fix the broken safety net, Congress should consider the following.
[17]
- Repeal Obamacare and its Medicaid expansion. One of
Obamacare’s greatest pretenses is that it improves access to health
care. The new law attempts to achieve this goal by dumping millions more
patients into the broken Medicaid system. Recent Heritage Foundation
research has statistically illustrated the debilitating effect that
Medicaid expansion will impose on state governments.[18]
Some proponents will likely argue that Obamacare addresses access
issues by providing additional federal funding to increase physician
reimbursement to Medicare levels. However, this additional federal
reimbursement is only temporary and solely applies to primary care
physicians. As a result, it is only a matter of time until state budgets
become more burdened and a lack of access to meaningful health care
becomes even more of a problem nationwide.
[19]
- Maximize access to private health insurance for Medicaid beneficiaries. The
best approach to improving access and outcomes would be to integrate
the success of private health insurance into the Medicaid system. Some
states, such as Florida, have pursued reforms in the past decade by
giving Medicaid patients a choice of private managed care plans. A
five-county pilot version of the program flattened Medicaid costs and
had been saving the state slightly under $120 million annually.
Additionally, the program overall noted greater access to care, higher
degrees of patient satisfaction, and a marked improvement in health
outcomes.[20]
The Heritage Foundation’s
Saving the American Dream proposal
goes further. It recommends transitioning non-disabled Medicaid
beneficiaries out of the failing Medicaid program and into private
health insurance and integrating private, patient-centered models into
Medicaid to better serve the disabled and frail elderly.
[21]
Conclusion
Medicaid is a prime example of government’s inability to
outperform—or even keep up with—the private sector. Academic research
has consistently illustrated that the program is associated with poorer
access to care and poorer health outcomes than private insurance. With
the right reforms, however, lawmakers can significantly expand Medicaid
patients’ access to private health insurance and put low-cost,
high-quality care back in the hands of those truly in need.
—Kevin D. Dayaratna is Graduate Fellow in the Center for Health Care Policy Studies at The Heritage Foundation.
http://www.heritage.org/research/reports/2012/11/studies-show-medicaid-patients-have-worse-access-and-outcomes-than-the-privately-insured
May 8, 2014
