As the federal insurance website healthcare.gov puts its birth pangs behind it, critics of the Affordable Care Act may well need another attack point. One is already emerging: It's an assault on Medicaid, the federal-state health program that's a linchpin of the effort to expand access to coverage for the poorest Americans.
We're being told that Medicaid is lousy insurance -- that many doctors won't accept Medicaid patients, that wait times for appointments are long, even that it's worse than no insurance at all!
These assertions are all part of the bills of indictment issued by conservatives like Avik Roy, the former healthcare advisor to the Romney campaign, whose pamphlet on the topic is titled, unsubtly, "How Medicaid Fails the Poor." The claims have reduced Fox News and the Wall Street Journal editorial page to paroxysms of indignation that any American should be forced into taking Medicaid.
If you've followed the debate over Obamacare thus far, you won't be surprised to learn that there's more, much more, to the story. Let's journey together.
The question of whether, or to what extent, Medicaid patients are denied access to doctors is examined in great detail today by health economist Austin Frakt of Boston University and the University of Pennsylvania, who calls it the "conventional wisdom."
The truth is far more nuanced, he observes, drawing from numerous earlier studies. A 2011 study published in the Journal of the American Medical Assn. found that, indeed, the percentage of doctors accepting new patients from public healthcare programs (Medicare and Medicaid) had fallen from 2005 to 2008 -- but that the percentage of those accepting new privately insured patients had fallen even faster. The access to care of Medicaid patients, the study concluded, was on a par with privately insured patients.
One reason that figures may appear skewed is that comparisons of access by Medicaid and private patients tend to cherry-pick the figures on private health plans. A 2011 survey of Chicago-area doctors compared Medicaid access to that of the most expansive Blue Cross Blue Shield network in the area. Do Medicaid patients have worse access than enrollees of that private plan? Probably; but so do enrollees in most other private insurance plans. (This study is part of Avik Roy's case.) Some doctors may be more averse to seeing Medicaid patients than others because Medicaid reimbursement rates are lower than Medicare and some private insurance. The remedy, of course, is to increase those reimbursement rates, with isn't a solution you'll hear much from Fox and the Wall Street Journal editorialists.
Then there's the issue of whether Medicaid patients do worse than those with no insurance coverage at all. Frakt, writing with healthcare experts Aaron Carroll, Harold Pollack and Uwe Reinhardt, pretty much put this to rest in 2011. Commentators who reached that conclusion, they found, "creatively interpreted" the data, producing studies "beset by analytic problems."
Medicaid patients, for one thing, are typically in worse health than the general population even when seeking care -- "sicker than uninsured patients... [with] lower socioeconomic status, poorer nutrition, and fewer community and family resources." Some studies try to control for this, but it's impossible to do so fully. No studies show that Medicaid actually harms health, Frakt and his co-authors observed; and virtually every study that has ever examined the question has found that health insurance always improves health.
The most shameful aspect of the assault on Medicaid is that it's helping to stigmatize a program crucial to helping millions of people get health coverage. The Affordable Care Act expanded Medicaid to cover Americans with incomes up to 138% of the federal poverty line, though the Supreme Court made the expansion an option of state governments. Fox and the Journal are bristling with stories of Americans "forced" by the act to accept Medicaid, as if this is a threat to their health and their dignity.
Consider the most widely repeated case, which originated last month as an op-ed in the Wall Street Journal and has since been retailed on Fox. It's the story of one Charlene Hopkins of Washington state, who manages to "eke out a living" as a part-time educator (according to her daughter Nicole, who wrote the piece). Hopkins was struggling to pay $276 a month for a bare-bones health plan. Her insurer canceled it and offered her a more comprehensive plan for $415, which she can't afford. On the Washington state insurance website, she found that because of her income, her sole option is Medicaid.
But she doesn't want that. She considers it "welfare." The offer, Nicole writes, offends "her dignity and independence and her sense of being a fully functioning member of society."
She may really feel that way, but why? Mrs. Hopkins had a bare-bones plan she could barely afford. (And that would burden her family or the taxpayers if she required healthcare it didn't cover.) Her alternative in the private market was a plan she couldn't afford at all. The government is offering her a fully compliant health plan -- for free. Her desire, plainly, is to be offered a good plan partially paid for by government subsidies that she doesn't have to think of as "welfare."
Let's point out that nothing in the law would prevent Hopkins from buying her own insurance, if she had the money, or supplementing Medicaid from her own resources. If Congress were really concerned about the "indignity" of Americans on Medicaid, nothing's stopping lawmakers from upgrading the reimbursement rate or even shifting all those people to the subsidies available to other lower-income Americans on the ACA.
One might take the indignation of Fox and the Journal more seriously if either ever advocated such steps. It's also worth noting that of the 25 state governments that have refused to expand Medicaid to cover more of their citizens (all Republicans), not a single one has claimed to be doing so because they don't think Medicaid is good enough -- their chosen alternative is no health insurance at all for people living at 138% of the poverty line or below.
That's the context of the coming attack on Medicaid's role in the Affordable Care Act. You have now been warned.