Prominent conservatives and members of the GOP have taken to claiming that Medicaid — the government health insurance program for the poor — doesn’t actually translate to improving people’s access to medical care.
“Talk to somebody that’s on Medicare or Medicaid. Ask them if the doctor and services that they used to be getting are available to them,” White House Press Secretary Sean Spicer said in a briefing on Tuesday after a scathing Congressional Budget Office report determined that an estimated 14 million Medicaid recipients would lose insurance under the GOP health plan. “I know so many times now, when you walk into the doctor, they have a sign that says we no longer accept Medicaid. I mean, that used to be a given, almost.”
In other words, Spicer suggests in this latest resurrection of the claim, it doesn’t matter that all these people will lose coverage because they aren’t actually getting health care with their insurance anyway.
Not only is this wrong, it also misrepresents the best evidence we have on how Medicaid affects patients’ relationship with the health system.
Researchers have consistently found giving people Medicaid improves their access to health care compared to those who go without insurance. This has been true in the primary-care and hospital settings. It’s also been true on self-reported measures of access to care. People even like their Medicaid, according to surveys.
“To make the argument that Medicaid doesn’t improve access compared to being uninsured is completely false,” said Benjamin Sommers, a health economist and physician based at Harvard University. “There’s no ambiguity on access to care. Medicaid unequivocally improves access to care for people.”
That doesn’t mean Medicaid is perfect, however. People on it often face barriers when they’re trying to get the health care they need when they need it. Here’s a quick review of what we know about how Medicaid affects access, and where it falls short.
When people gained a Medicaid card, they used more health care of just about every kind — from prescription drugs to Pap smears
There has been a slew of studies on how giving people Medicaid affects their health care access. They pretty uniformly show that the program has a very positive effect on access among its recipients.
In a study out of Oregon about Medicaid’s effects, researchers from Harvard tracked what happened to the winners and losers of a state lottery that offered Medicaid to 10,000 randomly selected Oregonians in 2008. (This is the closest we have to a randomized trial on health insurance — the gold-standard study methodology — so it’s been a treasure trove of information for researchers.)
There, expanding Medicaid increased health care access. When people gained a Medicaid card, they used more health care — of just about every kind you can think of. They used more prescription drugs, they saw the doctor more often, they got more mammograms, more Pap smears, more PSA tests.
When researchers parsed the Oregon data to see what impact expanding Medicaid had on emergency department use, there too they found an increase. In one study, people on Medicaid increased their emergency department use by 0.41 visits per person, or 40 percent relative to the group who didn’t get Medicaid. This was surprising, given that their primary care access increased too.
“When you give people access to the health system, they use the health system like everybody else who has insurance,” said Katherine Baicker, a health economist at the Harvard T.H. Chan School of Public Health and the lead researcher on the Oregon study. They simply use it more. “They go to the doctor’s office 50 percent more than people who don’t have coverage,” she added.
These findings are consistent with data from surveys from the ACA’s first two open enrollment periods. There, people self-reported “significantly improved trends in self-reported coverage, access to primary care and medications, affordability, and health.” The low-income Americans in states that expanded Medicaid also reported better health coverage and access compared to those in states that didn’t expand Medicaid.
So beyond the objective measures of increased access, people also feel their health care access improves after gaining Medicaid. They also like their Medicaid. Low-income residents surveyed in three states said they viewed Medicaid as equal to or better than private coverage. Those findings were echoed in a Gallup national survey. And how people feel about their health care counts for a lot.
People on Medicaid sometimes have long waits and trouble getting specialist care
There are plenty of ways the program could be improved. For instance, researchers have found a disparity in people on Medicaid’s ability to see specialists compared to those on private insurance. According to a Kaiser review of the research on how Medicaid affects access:
…Medicaid children appear less likely than privately insured children to receive specialist care for various conditions and more likely to have trouble finding a physician willing to accept their insurance … Consistent with those results, “secret shopper” and other studies have found specialist physicians and clinics far more likely to deny appointments to Medicaid and CHIP children than to privately insured children, and much longer wait times for appointments for publicly insured children…
In a nine-city audit study investigating adults’ access to specialist care, 64% of callers saying they were privately insured, but only 34% of those saying they had Medicaid, were able to secure an appointment for urgent follow-up care for three serious conditions, suggesting that Medicaid adults may lack adequate access to specialist care.
Generally, a smaller share of physicians accept new Medicaid patients compared to the privately insured or Medicare patients. The program’s lower payment rates, the difficulty arranging specialist care, and the higher administrative burden are the often cited explanations for this gap. “The patients are also complex clinically and socially,” Sommers said. So they may be seen by some doctors as more hassle for less money.
In one of the newest papers to demonstrate this, recently published in the New England Journal of Medicine, the researchers used data from a national health survey to compare changes in health outcomes in states that expanded Medicaid to states that didn’t. Here, low-income adults in Medicaid expansion states reported increased wait times. (They also reported that they were less likely to go without medical care —including follow-up care, visits with specialists, and medications — because they couldn’t afford it.)
Another recent study on the subject, in JAMA Internal Medicine, came to similar conclusions on wait times. The researchers posed as new Medicaid or commercial insurance patients and called doctor’s offices in 10 states (some expanded Medicaid, some didn’t) asking for an appointment. The calls went out in two rounds: before Medicaid expansion in most of the states (2012 and 2013), and again in 2016.
The availability of appointments for Medicaid patients improved during the study period (while it remained stable for the commercial insurance called). But wait times also increased, this time for both the private insurance callers and the Medicaid callers.
“A few things could be going on here,” said Sarah Miller, a University of Michigan researcher and lead study author on the NEJM paper, over email. “It could be that people indeed access care, but they need to wait longer for it, which is not necessarily a contradiction.” In the case of her research, it might be that the wait times aren’t actually increasing, but people are just reporting them for the first time since they’re finally getting health care.
Let’s not lose sight of the bigger picture, though. Miller’s co-author, University of California Los Angeles’s Laura Wherry, pointed out: “Not only do we find that access to care improves with Medicaid, but we also find evidence indicating that low-income adults gain financial protection in the event of illness or injury. We find fewer reports of inability to pay medical bills and of worry about medical bills in the event of an illness or an accident.”
So Medicaid isn’t perfect. But the evidence suggests the GOP line that Medicaid only gives people a Medicaid card, but not more health care, is clearly wrong.
It also has some internal contradictions. If Medicaid patients truly weren’t using more health care, then their insurance wouldn’t cost the system much. So why does the Republican party seem so bent on taking Medicaid away from people?
According to the best estimates we have, the plan to take away the health insurance of 24 million people, as the GOP would do, would lead to more than 24,000 additional deaths in the US annually — more than the death tolls from firearm homicides, HIV, and skin cancer in the US each year.
The GOP will have to grapple with the fallout from this looming tragedy and the internal contradiction in their arguments as their push to repeal and replace the Affordable Care Act moves ahead.