In my previous post I argued that the Affordable Care Act will make it harder for Medicaid enrollees to access care, largely due to an increase in the demand for medical services from the previously uninsured. In this post I review studies which suggest that there is a severe quality problem in Medicaid. (More information can be found in chapter 15 of my Independent Institute book, Priceless: Curing the Healthcare Crisis.)
Here are some studies identified by American Enterprise Institute scholar Scott Gottlieb:
A study published in the American Journal of Cardiology found that Medicaid patients were more than twice as likely to have a major subsequent heart attack after angioplasty, compared with patients who had no health insurance at all.
A study of patients undergoing lung transplants for pulmonary diseases, published in the Journal of Heart and Lung Transplantation, found that Medicaid patients were 8.1 percent less likely to survive ten years after the surgery than their privately insured and uninsured counterparts.
In each of these studies, researchers controlled for the factors that can increase poor health outcomes in Medicaid patients. Almost everyone agrees that Medicaid is not as good as private insurance. A more contentious issue is whether Medicaid is better than no insurance at all.
Here are some additional studies identified by Forbes health blogger, Avik Roy:
A University of Virginia study found that individuals enrolled in Medicaid are almost twice as likely to die after surgery as privately insured patients, and about one-eighth more likely to die than the uninsured.
A study published in the Journal of the National Cancer Institute found that Florida Medicaid patients were 6 percent more likely to be diagnosed with prostate cancer at less treatable, later stages than the uninsured. Medicaid enrollees were nearly one-third (31 percent) more likely to be diagnosed with late-stage breast cancer and 81 percent more likely to be diagnosed with melanoma at a late stage. (Medicaid patients did outperform the uninsured on late-stage colon cancer.)
A study in the journal Cancer found that the mortality rate for Medicaid patients undergoing surgery for colon cancer was more than three times as high as for the privately insured and more than one-fourth higher than for the uninsured.
A study in the Journal of Vascular Surgery found that Medicaid patients treated for vascular problems, including plaque in their carotid (neck) arteries that pump blood to the brain and obstructions in the blood vessels in their legs, fared worse than did the uninsured (however, the uninsured with abdominal aneurysms fared worse than Medicaid patients).
With respect to cancer care, it is unclear that Medicaid matters very much. After reviewing the literature, Roy concludes that Medicaid patients do no better and sometimes worse than the uninsured.
Health economist Austin Frakt takes issue with these studies, claiming that Medicaid and non-Medicaid populations are fundamentally different, even after adjusting for race, income, and other socioeconomic factors. That claim seems improbable—at least at the margin—however, in light of the heavy ping-pong migration of people in and out of Medicaid eligibility. Put another way, people who stay enrolled in Medicaid continuously probably are different from people who never enroll. But the most interesting group is the group that migrates back and forth.
Frakt points to some studies finding that Medicaid makes a positive difference over being uninsured. But the results would probably have been just as good or better if we spent the money giving free care to vulnerable populations. Moreover, even with their Medicaid cards, enrollees turn to emergency rooms for their care twice as often as the privately insured and the uninsured.
A RAND report on expanding Medicaid coverage in Oregon turned up some positive effects. The Oregon Health Insurance Experiment found that those with Medicaid were one-third more likely to see a doctor, 15 percent more likely to fill a prescription, and 30 percent more likely to experience a hospital stay. Very poor and sick individuals enrolled in the program also reported that having Medicaid insurance made them feel healthier. However, economist Robin Hanson points out that about two-thirds of these effects occurred after being accepted into the program, before any care was actually received.
Next we will look at waste in Medicaid.