OP-ED

How Can Patients on Medicaid Possibly Be Worse Off than Those Who Don’t Have Insurance?

“Extraordinary claims require extraordinary evidence,” said Carl Sagan.

The claim that health insurance improves health outcomes is hardly ground breaking. Studying whether insurance affects health status is like wondering whether three meals a day lead to a higher muscle mass than total starvation.

Well that’s what I thought. Until I read the study on Oregon’s Medicaid program by Baicker and colleagues in the NEJM earlier this year and, more recently, Avik Roy’s short treatise “How Medicaid Fails the Poor”.

Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.

The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.

The one thing the study did not lack was sample size. It’s useful to bear in mind sample size. Large effects do not need a large sample size to show statistical significance. Conversely, if study with a large sample size does not show even a modest effect, it means that the effect probably does not exist.

There are several interpretations of the Medicaid study, interpretations inevitably shaped by one’s political inclination. The ever consistent Paul Krugman, consistent in his Samsonian defense of government programs against philistines and pagans, extolled critics of Medicaid as “nuts” and asked, presumably rhetorically, “Medicaid is cheaper than private insurance. So where is the downside?”

Unlike Krugman I am not a Nobel laureate and am about as likely to win a Nobel Prize as I am of playing the next James Bond, so it’s possible that I am missing something blatantly obvious.  Could the downside of a government program paying physicians, on average 52 cents, and as low as 29 cents, for every dollar paid by private insurance in a multiple payer system be access?

Indeed, it’s darn impossible for patients on Medicaid to see a new physician.  As Avik Roy explains “…massive fallacy at the heart of Medicaid….It’s the idea that health insurance equals healthcare”.

But wait. It gets better.

I am accustomed to US healthcare throwing more plot twisters than Hercule Poirot’s sleuth work. But one I least expected was that patients on Medicaid do worse than patients with no insurance (risk-adjusted, almost). I am not going to be that remorseless logician, which John Maynard Keynes warned us about, who starting with one mistake can end up in Bedlam, and argue that if you are for Medicaid that is morally equivalent to sanctioning mass murder. Rather, I ask how it is possible that possessing Medicaid makes you worse off than no insurance whatsoever.

To some extent this may artifactually appear so because poverty correlates with ill health, and studies that show Medicaid patients faring worse than uninsured, cannot totally control for social determinants of health.


However, I found a plausible explanation during a recent conversation with a physician specializing in physical medicine and rehabilitation (PMR). She ran a special clinic one day a week in which she saw adolescents for free. These kids had no insurance. They were mainly from the local Hispanic and African American communities.

She did not accept Medicaid patients. This point is worth parsing out again. This doctor is happy to see patients uncompensated but not Medicaid patients, partially compensated.

Why so, I asked, bewildered and feeling that I must be in Bedlam.

The physician explained that the transaction costs in billing Medicaid are so high, that it’s not worth the tiny return. Plus one is exposed to unintentional billing fraud, audits, compliance and perpetual war with formularies and pharmacies. She ran her practice as a small business and kept her support staff to a minimum; she simply could not afford the legal and coding help that this would entail.

Ahh, I asked with that “gotcha” feeling, why could she not see Medicaid patients for free on the clinic day that she sees other youngsters uncompensated.

She explained that if she saw all Medicaid patients for free she would technically be committing fraud. Unless she made a nuanced determination to waive fees on an individual basis. At any rate it would unduly burden her, and it was a good deed that best remained unpunished.

Again this is worth parsing out because this is so mind-boggling. Seeing all patients on Medicaid for free is fraud! That’s what this physician believed and what I am told many physicians believe.

I am a simpleton. When I hear “fraud” I think of Madoff, Ceausescu and saying you were given the wrong beer after finishing two-thirds of the bottle at a restaurant. I also understand that after attending law school one’s tryst with simplicity ends forever.

Even though this is probably an exaggerated application and interpretation of the Anti-Kickback Statue, it is difficult to resist the urge to violently shake the framers of Medicaid statutes and yell “what on earth were you thinking, sir and madam?”

Medicaid is a prickly issue. It polarizes. The left sees any attack on Medicaid’s effectiveness by the right as an excuse to throw the program out and replace with nothing. This is plainly shooting the messenger, sometimes. The Pavlovian reaction is understandable as some on the right see in Medicaid scientific vindication of their anti-welfare stance.

But if an individual loses 30 pounds despite a complete diet inquiring about the underlying problem, whether there is a malignancy or not, does not challenge the value of eating.

How utterly incurious must one be to not wonder after the Oregon experiment and several other studies, why? How can you possibly not at the very least inquire whether Medicaid is a structurally sound program?

Roy’s opinions are a little to the right in health policy. But he accepts as do many on the right that the poor should not be thrown under the bus. On Medicaid, the left and right are in that rare agreement.

The mark of a civilized society is how it deals with the poor who are sick. An intelligent society distinguishes itself from an ideological one by acknowledging that the system in which the poor remain sick needs restructuring.

A Manichean view would regard rapacious capitalism as the cause of all ills. But rules and regulations of leviathanic proportion hurt. And we would shock even Mr. Limbkins if we asked for “More” of the same.

Saurabh Jha, MD (@RogueRad) is an Assistant Professor of Radiology at the University of Pennsylvania. His scholarly interests include the value of imaging and dealing with uncertainty in clinical decision making. Jha views most problems in medicine as problems of imperfect information. He trained in the UK and migrated to USA for more predictable weather and a larger yard.

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93 replies »

  1. I have had private insurance for 25 plus years. Recently my back degeneration on all levels caused so much pain I could no longer work. I went to see a neurologist and on my first visit it had my private insurance listed. He was wonderful, caring and very supportive. My second visit my chart was updated and I walked out of the office feeling like I had just been scolded by a parent. It was horrible and he acted like I was completely wasting his time. My daughter was livid!! She called him a bastard (after we got in her car) and could not believe how dismissive he was. Yes, he works for a state funded medical college and must accept Medicaid. He left me with numbness and no reflexes in my upper extremities. What the hell fid I do to ever deserve being treated like this!!

  2. As a person that has had very good insurance to no insurance to Medicaid to good insurance again, I have experienced being a patient under all these umbrellas. What I found are very clear problems. First, I had a difficult time finding a doctor who would accept me as a Medicaid patient. And, when I did, I was treated more like a number than a person. Unfortunately, more doctors than not were stern and acted bothered they had to deal with me. I had one doctor actually cuss when he saw I had Medicaid. I was in shock and didn’t go back to him even though I knew it would require me spending days on the phone trying to get someone to accept me. Another time, an eye doctor jumped on me and asked why I changed to him, then said in front of my pre-teen son, it must be due to the other doctor not accepting Medicaid. He was unfriendly with my son during the exam and when we left my son was upset. I wanted to walk out, but knew I had to keep my composure due to my son. My son talked at length about how the doctor treated us, and I framed it that having character isn’t a pre-req for being a doctor.

    Another issue I had while having Medicaid is: out of 16 calls to doctor’s offices to find a primary doctor, I had 7 tell me they weren’t accepting new patients (this was after they asked what insurance I had), the remaining secretaries told me they’d have to check with the doctor and would call me back. I received one call back. When I was lucky to find a job I could buy good insurance (it took most of my check), for research purposes, I called the same doctor’s I called when I had Medicaid. There were no problems getting in, all but one who previously said they weren’t accepting new patients were now accepting new patients. Then, probably the most disturbing is the difference in treatment. As a Medicaid recipient, I had subpar medical care. The difference in care for the same health issues were surprising, especially evident when seeing a dentist. It was almost impossible to find a dentist; I had to drive an hour away after days of calling every place in a 30 mile radius, I had to keep going farther out. Then, when I was able to get regular insurance again and see my regular dentist who doesn’t accept Medicaid, he was upset I lost those teeth unnecessarily. What I’ve went through has disturbed me so badly, I feel a real sense of injustice. As you know, missing teeth makes it harder when they’re visible to find employment. This can create a vicious cycle that keeps people trying to climb out of poverty further down into it’s grip. I used to be an idealist, thinking doctors do whatever is needed for a person, surely they wouldn’t deny people adequate care because they’re poor at the time. What I found is healthcare is not equal for all!

  3. Wow! Thank you for the insight into the emotional states of Medicaid patients vs those with no insurance. Your ESP is truly impressive.

  4. “Without legal protections and institutions to carve out the issue of individual rights from democratic vote, democracy just degenerates into packs of wild dogs seeking to devour each other for survival.”
    __

    Do you inhabit a permanent irony-free zone?

    “Legal protections”

    Which have to be administered by society. Again, your “rights,” as empirical matters, exist to the extent that others will uphold and enforce them.

    Theoretical philosophizing is great fun, to be sure, but it falls short of encompassing coherent reality, as aggravating as that might be.

    Deductive axiomatic proofs work fine in Algebra I.

  5. The costs are diffused, therefore no longer marginal, and the benefits uncertain, so also not marginal. Regardless, the pricing is distorted. Imagine if hotel in Vegas has guaranteed 90 % occupancy. The 10 % price is affected by the certainty of the 90 % occupancy.

    The comparison to other public services is interesting. I don’t have a counterpoint at this moment but will have to think a bit about the NHS.

  6. “The consumer, for want of a better term, does not incur the marginal cost of the marginal benefit.”

    The uninsured cash pay sure as hell does. The insured see their deductibles, co-pays and premiums rising but are locked in a “can’t do without” service. The employer system sees the “marginal benefit”, especially those self insured.

    We accept and support fire departments and water/sewer systems and road construction and police as necessary government run services paid through taxes, and we support private utilities being regulated by government, but somehow can’t fathom health care and its necessity as better handled by government. We complain about mega cartels in hospitals and insurance controlling the “system” yet think even less government regulation/control will make them more accountable.

    The present system is delivering services but failing to control costs in relation to wage increases. Do you really think the private sector “cartels” are anxious to fix this? Maybe when we spend 20%+ of GDP on health care that sucks spending away from other industries will we get a big enough 2×4 across the head to wake us up.

  7. I would be inclined to agree with 64 on this. The hospital prices is not free market capitalism. There are no price signals. The consumer, for want of a better term, does not incur the marginal cost of the marginal benefit.

    Prices are distorted by third party payers.

    The system has a lot of faults but adhering to free market capitalism is not one of them.

    The role of the government is both necessary and necessarily complicates. The pill and its side effects are inseparable.

  8. “Bear in mind these are all responses to and consequences of government regulation in one form or the other”

    Hogwash. Government does not dictate architectural design. The fact that hospitals are in competition with each other is the reason they build what people blindly perceive will give them the best care – competition is the devil. Mega hospital systems are a natural course of corporate expansion. What you despise is capitalism health care – how do you wish it be ended, by “government” action?

    I see by your comments you are a Libertarian – one step above anarchy. Libertarians profess that there is no community, but just every man for themselves. Under you view school taxes are “coercive govt taxation”.

    If you are a real doc then you know that here no system binds you to rely on insurance, just go cash pay, it’s being done. You can treat the payers and scorn the rest.

  9. Peter1,

    yes, on the palatial granite lobbies and consolidation into mega hospital systems that jack up overhead costs, creates local provider cartels, lower competition and result in inflated medical prices.

    Bear in mind these are all responses to and consequences of government regulation in one form or the other – and bad government policy in the health insurance market – not of a free market.

    Regarding charity care, Medicaid is not “charity” by any stretch of the imagination or rational definition – since it is based purely on coercive govt taxation – rather than voluntary contributions. As such, it violates the property rights of those who are forced by the government to pay for other people’s care.

    Revising the tax code to incentivize private, voluntary medical charity donations- of time and money -is not “getting to single payer” since it respects the rights of each individual to his life and property, including voluntarily offering his time or money to help others at his discretion.

    ” No unequal health tiers” = egalitarianism = health care goods and services as a right?

    Some have the right to work and earn money pay for their services?
    While others have the _right_ to be given these things without effort – and the right to force other people ( thru govt ) to pay for or provide those services? Not in a free society.

  10. Radsdoc, I appreciate how you are trying to work through the costs of health care. It ain’t easy.

    You wonder why technology raises health care costs, while it lowers costs in other sectors..

    You blame government.

    The

    Say that in the past we could treat heart attacks with two weeks of bed rest.

    Now we have angioplasty and stents. I had a heart attack myself and I went home in 3 days.

    What I think has happened is that hospitals used to charge $15,000 for two weeks of care, and now they charge $15,000 for 3 days of care.

    The non-health care economy is very different. Say that yesterday a corporation had ten people to a conference center for a meeting and spent a total of $20,000.

    Now a video conferencing firm comes along and can conduct a virtual meeting for $3,000 with online video.

    The corporation cancels the hotel reservations and goes with the video.

    Hotel personnel lose their jobs.

    This has not happened in health care. The culprits are more than just government.
    \

  11. “dictating whatever arbitrary price it wants”

    That is completely false. You state this as if the providers, device makers and drug companies are slaves – they are not, and any negotiated prices/compensation has to be tempered with the fact that these entities can withdraw their services.

  12. Even county EMS bills patients in North Carolina. Whether they collect from the uninsured is unlikely, but they do bill Medicaid/Medicare/Tricare/Blues/Commercial.

    Funded by tax dollars unleashes the taxi mentality. It must never be free. It must cost the user something and the programs supporting the patient must collect the copay and fully pay the provider of the service.(Medicaid/Medicare, etc.

    It should have been that way all along…would have prevented lots of abuse.

    But these are political programs, afterall. No real actuarial basis for them.

    The government will never enforce any negatives on the 47%ers.

  13. Free at point of service increases demand, I agree.

    But demand is also a function of what is there. You can’t demand something that does not exist.

    In your analysis you should ask whether the US healthcare would have reached this size through the market.

  14. So you’re for compulsory non-group individual policies which are tax deductible?

    How do you police hospital “price gouging” when there are no competitors in a market?

    “some of which are fascist in nature”

    Examples?

    “A crap system everywhere it’s been tried”

    Seems no one in those “crap systems” are looking to overthrow them.

    “equally lousy care on waiting lists for all”

    http://www.washingtonpost.com/blogs/wonkblog/post/americas-waiting-times-are-the-worst-in-the-world/2011/05/09/AFGIxr2G_blog.html

    Wait lists are a creature of cost control, or if you will rationing. Everyone is trying to manage them to balance between cost and access, especially in a growing aging population. You seem to think we can have all the care we want at cheap prices. In Canada, as with other single-pay countries care is free with tax support – but they do it for about half the cost of the U.S. Do you think we can do it for half with unfettered access? Where might that magic health system already exist?

    The problem with health care you don’t seem to grasp is no one wants the cheaper version as they would a car. We all want to get from A to B but we can get there in a subcompact or luxury car – but we all get there the same (roads paid by taxes). How do you get top health care treatment with subcompact prices where we all end up the same?

    If you don’t want “wait times for all”, who do you think should wait?

  15. Saurabh, I think you will agree that you cannot safeguard, protect or implement any principle or policy without first defining and understanding what it is you are trying to implement or protect. As such, definitions matter.

    What your comment demonstrates though is the importance of definitions – as well as the well accepted fact that pure “democracy” in and of itself is synonym for – or political system – which leads to freedom, but rather tyranny.

    When the mob is empowere to vote on any and every issue- including the issue of whether or not any individual in society has a right to his life, liberty or property- or it can be disposed of by its leaders to servce their benefit, you do not have a cilvized society but gang rule .

    Without legal protections and institutions to carve out the issue of individual rights from democratic vote, democracy just degenerates into packs of wild dogs seeking to devour each other for survival.

    The below describes the essential differences far more eloquently than I could ever hope to:

    “The American system is not a democracy. It is a constitutional republic. A democracy, if you attach meaning to terms, is a system of unlimited majority rule; the classic example is ancient Athens. And the symbol of it is the fate of Socrates, who was put to death legally, because the majority didn’t like what he was saying, although he had initiated no force and had violated no one’s rights.

    Democracy, in short, is a form of collectivism, which denies individual rights: the majority can do whatever it wants with no restrictions. In principle, the democratic government is all-powerful. Democracy is a totalitarian manifestation; it is not a form of freedom . . . .

    The American system is a constitutionally limited republic, restricted to the protection of individual rights. In such a system, majority rule is applicable only to lesser details, such as the selection of certain personnel. But the majority has no say over the basic principles governing the government. It has no power to ask for or gain the infringement of individual rights.”

    http://tinyurl.com/yhwq9po
    and
    http://tinyurl.com/mezbmwt

  16. I am under no illusion, and neither should anyone else, that treating the most economically disadvantaged section of society costs. Of course, I think it is worth the cost.

  17. Thanks for your comments, Barry Carol. Regarding the price of hosptial care, I have no doubt that hospital prices in other countries are lower, though I would examine closely the concept of “similar stringent regulation”.

    Most of the health care systems in the rest of the world are government run and paid for – completely socialized single payer. In contrast, the US has been over 50% socialized since the institution of Medicare and Medicaid, has only increased over the past 50 years and is well on its way to a wholly run government system.

    In a government run single payer system, there is no question that the government can set and does set price limits / price controls- dictating whatever arbitrary price it wants to somehow restrain somewhat the skyrocketing regional health care budget that results when citizens exerciese their “right to ‘free’ unlimited health care services”

    Problem, of course, is that unlimited quantities of any good or services necessarily has unlimited cost and the only way to achieve this is through limiting access/ availiabilty of the goods or services through rationing.

    Rather than being a reflection of increased efficency or operating costs, the comparatively lower prices observed in other countries is largely a reflection of single payer government run health care- the power of a government monopoly to dictate prices as well as the rationing of technology and health care services.

    In the US, the CMS government run sector sets price controls as any govt monopoly. In fact, it often sets prices barely above or even below cost of care, either creating a discentive for providers to take on patients or offer a particular service and shirfting billiions of dollars of unreimbursed costs onto what’s left of a “private” insurance market here.

    Thanks to faovrable government regulation and waiving of anti-trust laws, have largely consolidated and evolved into local govt-protected cartels able to dictate prices to providers and hospital systems – who responded with massive consolidation into their own govt protected cartels who push back and can now dictate prices to the insurance cartels. Health care in the US is nothing more than a bureaucratic battle between govt run or govt created cartels – rather than a private enterprise between individual patients and their doctors.

    By and large, the US medical system is the only one that contains some minor vestige, though rapidly vanishing element of private enterprise and free markets – which is also the element which has resulted in a greater degree of techonological discovery, widespread implementation and availability.

    It’s true that there is much more advanced life-saving and life-extending technology now than existed 50- 60 years ago . However, technology by *itself* does not raise costs. We also have advanced computers, tablets, e-readers, cells phones and lots of other technology that was not even dreamed of 50-60 years ago.

    What raises costs is govt funding of technology. All technology goes thru a phase where it is initially expensive and only available to a few early users who can afford it. As the techoology matures, more effiicient ways of production are discovered, more producers enter into the market, and the technology is now available on a mass market to a much wider segment of the population at a dramatically lower price and to larger segments of the population. This is what happened in computers and all other unregulated segments of the economy.

    What makes medical technology expensive in the US is the concept that somehow health care/ medical technology is a “right” – which can be demanded and provided in unlimited quantities by anyone and everyone regardless of ability or even intention of paying for – but that may be pushed onto one’s neighbor if one doesn’t feel like paying for it.

    We have created a system which empowers the govt and pseudo private insurance cartels to collect umlimited taxes and premiums to indulge the irrational notions of the American people that they have a birth -right to unlimited medical technology that it is “free”- to be paid for by others, but that they will never, ever feel the consequences of this themselves.

    An excellent link on the destructive consequences of government’s ill conceived foray into the health care market is here:

    http://mises.org/daily/3793/American-Healthcare-Fascialism

  18. Lot of good ideas here, but let me offer one clarification:

    the $450 billion spent on Medicaid does NOT all go toward primary care for poor people and their ER use.

    over two thirds of the $450 billion goes for nursing homes and for very expensive care for disabled persons.

    The young mothers and their children in the shabby clinics are not what is driving Medicaid spending.

    One other note while I am thinking of it:

    Radsdoc64 wants private ambulance services………I think we have that now!
    Many Americans are hit with $1500 bills that are not covered by insurance or subject to a deductible. This is cruel and barbaric in a rich nation, in my opinion. We need to go back to municipal ambulance services funded by tax dollars. The money required would be microscopic compared to other federal health expenditures.

  19. Regardless of how intuitive the definition of a right, safeguarding its purity and its logical origins is down to the will of the majority. It should not be (ideal world) but it is (real world).

    In a system in which a certain section of the population is systematically disenfranchised, for whatever reason, these people will have little sympathy for the property rights that you so neatly define, if it means that they can vote for policy that makes their lives easier and if those policies interfere with the theorems of Ayn Rand or Euclid..

  20. Bobby Gladd,

    You seem to be confused regarding the difference between rights and permissions- like many people- including all statists. Clearly, my individual rights still exist, regardless of whether an individual or group or government chooses to respect and protect them. For the purpose of clarification:

    “A right is the sanction of independent action. A right is that which can be exercised without anyone’s permission.

    If you exist only because society permits you to exist—you have no right to your own life. A permission can be revoked at any time.

    If, before undertaking some action, you must obtain the permission of society—you are not free, whether such permission is granted to you or not. Only a slave acts on permission. A permission is not a right.

    Do not make the mistake, at this point, of thinking that a worker is a slave and that he holds his job by his employer’s permission. He does not hold it by permission—but by contract, that is, by a voluntary mutual agreement. A worker can quit his job. A slave cannot.”

    http://tinyurl.com/l824npy

    In contrast, an excellent philosophic explanation of what a right is:

    “A “right” is a moral principle defining and sanctioning a man’s freedom of action in a social context. There is only one fundamental right (all the others are its consequences or corollaries): a man’s right to his own life.

    Life is a process of self-sustaining and self-generated action; the right to life means the right to engage in self-sustaining and self-generated action—which means: the freedom to take all the actions required by the nature of a rational being for the support, the furtherance, the fulfillment and the enjoyment of his own life. (Such is the meaning of the right to life, liberty and the pursuit of happiness.)

    The concept of a “right” pertains only to action—specifically, to freedom of action. It means freedom from physical compulsion, coercion or interference by other men.

    Thus, for every individual, a right is the moral sanction of a positive—of his freedom to act on his own judgment, for his own goals, by his own voluntary, uncoerced choice. As to his neighbors, his rights impose no obligations on them except of a negative kind: to abstain from violating his rights.

    The right to life is the source of all rights—and the right to property is their only implementation. Without property rights, no other rights are possible. Since man has to sustain his life by his own effort, the man who has no right to the product of his effort has no means to sustain his life. The man who produces while others dispose of his product, is a slave.

    Bear in mind that the right to property is a right to action, like all the others: it is not the right to an object, but to the action and the consequences of producing or earning that object. It is not a guarantee that a man will earn any property, but only a guarantee that he will own it if he earns it. It is the right to gain, to keep, to use and to dispose of material values….”

    More here:
    http://tinyurl.com/mtr4owa

  21. RadsDoc64 –

    Thanks for one of the more interesting comments I’ve read in some time, especially as it relates to the cost of hospital care. I printed out the Friedman paper and will read it later.

    What I wonder about is the comparison of current U.S. hospital costs to those in other developed countries which I believe are much lower. Aren’t they also subject to similar stringent government regulation? Also, to what extent has the massive proliferation of new medical technology developed over the last 50-60 years impacted healthcare costs in the U.S. and elsewhere? My perception is that during the 1940’s and early 1950’s, there was comparatively little that medicine could do for us. I don’t think anyone would like to go back to 1950’s healthcare at 1950’s prices. I know I wouldn’t but I do think U.S. healthcare costs are excessive, especially for hospital based care even based on Medicare rates let alone the ludicrous chargemaster rates.

  22. In a restaurant you get Caviar when you order Caviar.

    If I suddenly collapsed in a shopping mall how will the passerby know whether to call Ambulance Caviar for the Hot Heart Institute with a door to balloon time of 15 minutes, or Ambulance Good Enough for the Oliver Twist Institute for the Destitute with a door to balloon time of eternity?

  23. Private ambulance services would be abundant since there would be no shortage entrepreneurial, skilled health care providers looking to earn a living by plying their trade and fulfilling a real need in society for stabilitizing emergency medical services and transport.

    Not sure what government could possibly add running an ambulance service in terms of medical skill, efficiency or anything- except in terms of layering on tons of waste/ fraud/ cost and bureaucratic paperwork-about the only thing government does well.

  24. In this perfect system that you so eloquently describe will ambulance services be provided by the market or the government?

    Because when I am having a questionable MI I really want to make sure that I get the tier care I paid for, nothing more, nothing less.

  25. Peter1-

    <>

    I am ‘for’ health care providers earning whatever income they will – same , higher, or lower- through a completely private system of voluntary trade by mutural benefit to mutual advantage between consumers and providers of health care services.

    I am ‘for’ patients having personal and portable, tax deductible real health insurance policies which protect them from bankruptcy by covering catastophic health caree costs, rather than the 3rd party payer scheme of utilizing and enriching 3rd party payer and government middlemen/ bureaucrats to process paperwork just so I can get a chest xray or lab test.

    I am ‘for’ transparent, stream-lined, competitive pricing of medical services wrung clean of all the parasitic middlemen who take their cut of every health care dollar and drive up costs of services by adding _zero_ value.

    In regard to hospital price gouging, thank the government regulation and the “non-profit” status that we’ve evolved to over the past 70 years:

    “In 1992, the Hoover Institution published an essay by Milton Friedman titled “Input and Output in Medical Care,” in which Friedman documented how, at the beginning of the 20th century, about 90% of all American hospitals were private, for-profit enterprises. State and local governments then began taking over the hospital industry. So, by the early 1990s only about 10% of all American hospitals were private, for-profit enterprises. Socialism characterizes at least 90% of all hospitals. Many other hospitals have received government subsidies, and with the subsidies come reams of regulation, making them fascist by definition.

    “The problems caused entirely by the fact that the government subjects the system to massive interventions, some of which are fascist in nature while others are socialist.”
    The effect of this vast government takeover of the hospital industry, Friedman documented, is what any student of the economics of bureaucracy should expect: the more that is spent on hospital care, the worse the quality and quantity of care become, thanks to the effects of governmental bureaucratization. According to Friedman, as governments took over an ever-larger share of the hospital industry (being exempt from antitrust laws), hospital personnel per occupied hospital bed quintupled, as cost per bed rose tenfold.

    Friedman concluded that “Gammon’s Law,” named after British physician Max Gammon, “has been in full operation for U.S. hospitals since the end of World War II.” Gammon’s Law states that “In a bureaucratic system, increases in expenditure will be matched by a fall in production.… Such systems will act rather like ‘black holes’ in the economic universe, simultaneously sucking in resources, and shrinking in terms of … production.” Dr. Gammon surely knew what he was talking about, having spent his career in the British National Health Service.”

    And you propose single payer? You apparently believe your own propaganda…..A crap system everywhere it’s been tried with doctor and technology shortages, and govt bureaucrats doling out equally lousy care on waiting lists for all. What a joke. “You pretent to pay us, we pretend to work”.

    http://mises.org/daily/3793/American-Healthcare-Fascialism

  26. How many extra Medicaid participants are needed to show a detectable effect with statistical significance?

    Answer: 17 million!

    What if study fails to demonstrate an effect?

    Answer: further research is needed!

    There is truth, damn truth & degrees of freedom.

  27. “The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.”
    ___

    WHAT? With degrees of freedom in the single digits (on a per patient basis, after only a couple of years)? Statistical naivete on steroids. Glomming them all together just gets you a a blob, a “Glom”, the ostensibly impressive aggregate “n” notwithstanding.

  28. Doc64,

    Charity donations are already tax deductible – for only those who itemize, one of my pet peeves. Expanding tax compensated care is getting to single pay.

    If you want taxpayers and insured to save money then you’re going to have to reduce prices. How do you plan to do that?

    Negotiating with hospitals is mostly ineffectual even with non-emergency care. Who do you negotiate with – the radiologist, the surgeon, the anesthesiologist, the doctors group, the drug company, the device provider? What standards does the hospital use to judge why patient A pays more than patient B? What negotiating power does the patient provide – volume purchasing? Hospitals in my area have amalgamated or have mutual working agreements – not much competition if that’s your solution. They also provide palatial granite lobbies and state of the art facilities much like resorts, where overhead is fixed. Some people are able to travel for better prices but there are income barriers to that as well.

    You want the tax system to compensate for “charity” care, but single pay already does that, except it rewards providers on pre-negotiated contracts based on budgets where ALL care is paid and is the best care that can be provided. There are no unequal health tiers such as private insurance, Medicare, Medicaid, self pay.

  29. Correct me if I’ m wrong, though given what you have pointed out above,
    I think you just described Medicaid, not private charity:

    “… messy, non-uniform and, over time, systematically punish the givers.”

    Even despite the current system, of extremely high taxation to involuntarily fund a poorly function government medical program like Medicaid and others, leaving them with less disposal income, every year Americans donate hundreds of millions of dollars to health-related charitable organizations such as American Red Cross, American Heart Association, Leukemia & Lymphoma Society, St. Jude’s Children’s Hospital, the Dana Farber Cancer Center, the American Cancer Society, and Susan G. Komen for the Cure.

    Fourteen of the fifty largest American charities are in the health-care sector, and many of these organizations help fund medical treatments for those who cannot afford them.

    Doctors already provide tens, if not hundreds, of hours of un-reimbursed or under-reimbursed care per year valuing in the thousands, if not hundreds of thousands of dollars.

    Why would this not continue, or increase, under a system of tax breaks or tax credits for medical charity which not only incentivize this behavior, but also offset the cost to the physician?

    The context of providing and funding emergency care you paint is unrealistic- in any system. Emergency care does not happen in a vacuum. A person in need of an urgent bypass or surgery for a ruptured aneurym or MVA is not delayed pending confirmation of ability to pay.

    True life -or-death emergency treatment, as you well know, requires immediate action – without delay – and no one I can think of would want to or advocate for, as society where they had to produce full payment in cash upfront or swipe a credit card at the point of service or be left to die. None of us is immune to such unpredictable scenarios.

    Yet, it is also stating the obvious to point out that a hospital or doctor’s practice is a business and cannot operate as a going concern long term in the red to even be in the position of being able to deliver _any_ health care services- routine, screening, planned, emergent or otherwise.

    So, in emergent scenarios, talking about payment takes place after the fact once the emergency medical situation has been addressed. In the event that a patient lacks insurance and his limited financial means make it impossible to pay the entire bill, there’s no reason why hospitals couldn’t be given tax credits or deductions for the delivered care.

  30. I am inclined to agree. It’s the worst form of healthcare, other than all other forms of healthcare (to slightly and clumsily paraphrase Churchill).

  31. Well Doc64, you must be for people in the health system earning less so “middle-classes” can afford their services? Does that include you?

    I’m no supporter of the medical/insurance-industrial complex (I’m uninsured by choice) but as with most physician sponsored “solutions” their main goal is to make docs life better, not necessarily patients lives, and they are driven by PCPs outside the hospital system, where, for the most part, costs don’t drive financial hardship.

    It’s the hospital charges that are killing us, the ones where there is no way to “negotiate” before services are provided. As with all negotiation each side needs an advantage to sell – what advantage do you think most middle-class people would have to negotiate with – “I just can’t afford it”?

    The notion that if somehow we could shop across state lines we could find better, more comprehensive policies at less cost, defies actuarial reality. In the real world cheaper policies mean less coverage – the risk is the risk.

    You also claim that docs really, really want to compete on price in an open competitive market – that does not even exist in dentistry or veterinary as these professions are unregulated. Do you think those unregulated professions allow low income patients to afford dental or veterinary services? In fact “professionals” want to compete on everything except price.

    “Furthermore, many legitimate medical injuries are not compensated. That leaves many patients – especially the poor, minorities and elderly, without the compensation they desperately deserve.”

    The reason many are not compensated is from state tort reform – which you seem to support. However the reason the “poor” can get, “the compensation they deserve” is due to contingency and the ability to sue.

    “with sliding scale federal support for low income individuals.”

    Give us the details of this new Medicare social program. Leaving out details makes “solutions” easy. Give us the support levels. In your “new system”, why would the elderly even need any federal support, couldn’t they just line up for free charity care?

    “Medicaid should also be gradually transitioned to a fiscally sustainable model by allocating funds to low income individuals, assisting their purchase of private health insurance.”

    Have you ever looked at the state income/asset rules to qualify for Medicaid? If so you’d find there is NO money left for “the purchase” of private health insurance let alone HSAs – somehow vouchers would solve that by paying them what the rest of us pay for insurance. Sounds like a social program to me. Couldn’t they just line up for free charity care?

    Why do you want to keep Medicaid at all when it pays docs so little compared to other payment systems? In fact Medicaid helps to deny the poor access, except to high cost ERs.

    Your solution to pre-exist coverage is exactly what the ACA is doing – “high risk patients would obtain premium assistance to purchase private health care insurance.” Your notion that somehow pre-existing conditions are the fault of the patient is just stupid. Your notion that, “the rest of us” healthy people should not subsidize the sick is farcical, and not what risk sharing (private or public) is all about.

    Your well worn “solutions” have been discussed on this blog many, many times, they still don’t meet the reality smell test. They rely on a nostalgic simplistic view of the country doctor seeing patients in a buggy and accepting chickens as payment.

    The best “solution” (there is never a final solution in health care) is government run single pay where prices are regulated, everyone has equal access, and the tax system supports payment (it’s not free). It’s portable, does not rely on employment and it’s “devoid of tax discrimination” as well as income discrimination.

  32. There is a lot of political philosophy and a smidge of objectivism in your post.

    Private charity would be messy, non-uniform and, over time, systematically punish the givers. It may not.

    What if a person needs emergency bypass surgery or management of arrhythmia? Would you want to live in a society where he cannot access those because his income falls below FPL?

    To a large extent, it becomes irrelevant whether healthcare is a right or not.

    The most vulnerable section of society cannot be abandoned to the caprice of charity.

  33. The penchant for citing studies that support one’s argument is prevalent across the political spectrum.

    So forgive me for not taking a binary view on this.

    I did not say the Baicker study showed Medicaid patients did worse than uninsured. Nevertheless, congratulations for destroying a strawman.

    I did say that some studies did show that remarkable finding (they do) that risk-adjusted Medicaid patients do worse and expressed incredulity (see comment regarding Carl Sagan).

    I also expressed incredulity that many physicians would rather see patients for free than Medicaid patients. This is the voice from the trenches, not ivory towers.

    For a program that will cost $7 trillion over the next 10 years and has been dubbed as genuine insurance does that not concern you?

    Medicaid does disservice to real people. Poor people. They are hardly served by an elite that gets touchy anytime someone questions the structure of the program, not its goals.

  34. Quick follow-up – given your own comments to Peter1 about the value of randomization over cross-sectional data (and that you’re a physician so you understand RCTs) – the Oregon study should absolutely put to rest the spurious notion that Medicaid is worse than no coverage. And it should absolutely put to rest the notion that Medicaid doesn’t improve people’s access to care. While evidence of health benefits of coverage may be less clear, can you show me *any* evidence from the Oregon papers that people suffered by getting Medicaid? Doesn’t that answer the question in your title?

    “How can patients on Medicaid be worse off than those without insurance?” They’re not – as your own preferred study shows. Avik Roy and co. will need to find another partisan argument to shout down attempts to expand health insurance – or (sadly) continue to selectively cite the Oregon study as they see convenient.

  35. Roy likes to cite cross-sectional studies with minimal risk adjustment for the things that truly differentiate Medicaid patients from others – education, health literacy, clinical complexity, and social circumstances. They’re terrible studies for evaluating the causal impact of Medicaid – and if you read the original papers, the authors generally don’t claim they are doing so – Roy knowingless takes them out of context.
    The Oregon studies are air-tight in terms of casual inference, but only small numbers of people in the study actually had diabetes or high blood pressure in the first place. (By the way, do we not care if people report feeling better? Self-reported health, mental health, and health-related quality of life all improved significantly in Oregon)…
    Another NEJM paper (also with Baicker as one coauthor) used a more comprehensive health measure over a longer period of time, with a natural experiment a lot like the ACA. They found that Medicaid improved survival:
    http://www.nejm.org/doi/full/10.1056/NEJMsa1202099

  36. Saurabh- As you seem to concur, the private charity model can work with PCP’s . I also see no reason why urgent care centers could not be funded and operated in similar fashion- with funds and time donated voluntarily by private citizens, corporations, religious organizations, etc and staffed by voluntary medical providers. All of the above could be incentivized by revising the tax code to include tax credits or tax deductions to donate time and money to build and sustain private medical charities.

    I disagree about the idea of interdependence blurring the concept of individual rigthts or private property.

    If you produce or earn money/property/ any value through the investment of your own time, mental or physical effort and money, you own it. Period. That is your private property to keep, use or dispense with in whatever way you see fit and neither I , nor the government, have a moral claim to it against your permission. Only an immoral one- based on the presumption that your rights can be sacrificed for the sake of my wants or needs .

    Peter1- the above “solution” is a substitute for the inept, inefficient, financially and morally bankrupt medical entitlement program affectionately known as Medicaid- not a proposal for sorely needed reform of today’s highly regulated, pseudo- private, quasi-governmental health insurance cartels.

    As the quote that you cherry picked aptly points out, it is the corrupt featherbedding of health insurance policy by lobbyist -influenced government insurance commissioners and policy makers which progressively jacks up the price of policies beyond the reach of the middle class, making insurance less and less affordable.

    Excellent solutions for real health insurance reform which would smash the govt-created insurance cartels, reform the market for health insurance and significantly bring down the price of premiums with real competition and patient consumer choice are here:

    http://docs4patientcare.org/prescription

  37. “An excellent example of a working model for providing care to the indigent has been operating in NJ for years and is described here.”

    “As the declining economy erodes America’s middle class, the nation’s healthcare system continues to spiral out of control, sending even more patients to this free clinic: From 1,700 patient visits in 2007, the clinic is on track to see 3,000 this year.”

    “Meanwhile, people like Amal found it hard to buy individual health insurance policies. Policy-makers in New Jersey, where Amal lives, have so generously defined the benefits required for a standard policy that individual insurance is beyond the reach of all but the affluent. Individuals purchased 220,000 policies in New Jersey in 1996, but only 90,000 in 2004.”

    Looks like we could abandon private insurance for your “solution”. Do you have a solution for the scores of people forced into economic circumstances that make health care unaffordable?

  38. In your model of voluntary private charity the do-gooders will be out of business quite soon. This can work at the level of the PCP but not emergency department. Indeed, this was one of the reasons that EMTALA was instituted.

    It’s good to protect individual rights, but society is far more interdependent today than 200 years ago. Defining private property is difficult.

  39. I would say alternatively that the mark of a civilized society is how its government and its citizens deal with the issue of individual rights.

    Does its government respect and protect the individual’s right to his or her own life, liberty or property? Do its laws forbid violation and punish violators of those rights?

    Or does the government actively violate the rights of its citizens through its laws and serve as an agent for the legalized and institutionalized violation of individual rights, liberties and property rights of its citizens ?

    This is the difference between a civilized society where individual citizens co-exist peacefully, respecting their neighbors rights and fulfilling this or her own needs by voluntary interaction, production and trade and a mob of savages looking for any oppportunity to advance his life by bashing his neighbor’s skull and stealing his property- ( or “democratically” contracting out his dirty work to a politician to collect his plunder while even legalizing it and whitewashing it in the name of morality and the “the good of society” .

    This only works until the next guy comes along who wants his piece of your life and your property and has a bigger or more ruthless gang of politicians in his pocket.

    In regard to Medicaid – or government coerced “charity”. To call it such, of course, amounts to intellectual dishonesty since charity is, by definition, voluntary. Dr. Jha has amply shown why the government run system is expensive, inefficient and does not work.

    There are, however, many other private, voluntary models whereby the medical needs of the truly indigent could be provided for voluntarily by those who wish to and would be incentivized to provide or help fund their medical care, if lbloated, self-serving government bureaucracy were to get out of the way.

    An excellent example of a working model for providing care to the indigent has been operating in NJ for years and is described here.

    http://www.worldmag.com/2009/11/patients_partners
    and
    http://www.worldmag.com/2005/06/healthy_alternative

  40. The Medicaid expansion in the Oregon study was on the basis of a lottery, providing the randomization that is near impossible, as you recognize, is social science research.

    Several other studies have shown that Medicaid patients have worse outcomes than the uninsured, after risk adjustment. These studies are not as well designed as the Oregon, meaning no randomization.

    The crucial point is Medicaid does not mean access. The question to ask then is why is access so difficult.

    I am sure you are right in stating that many on the right do not want to be seen to throw the poor on the bus, but derive no great sadness from that happening. This, however, is a problem across the political spectrum. Some on the left pay lip service to helping the poor but lose little sleep.

    One could argue that not addressing a program with problematic infrastructure is also feeding a poison of sorts.

    The world is full of righteous charlatans. I am not going to pick my favourite.

  41. I read your article several times and still don’t get it.

    “The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables.”

    Is this even possible given all the variants?

    Did the study tell us how they are worse off? Could we say then that Americans seeing doctors are worse off than those who don’t see doctors?

    I would say that the “right” is better described as not wanting to be “seen” throwing the poor under the bus. Policies, especially in the south, feed them slow untraceable poison.

  42. “In Taiwan, excessive users of the healthcare system get a talking to by someone in authority. Maybe we could try something similar.”

    Barry, that’s possible because they are single-pay and have a health card which tracks their usage of all services. Think about how that will be possible here if the gov’mt calls you in for a scolding on using the system too much.

    I bet the NSA has that data though, maybe they could act as the use police.

  43. I was just reminded of this (viewing the ER as better quality care) yesterday. I’m a doctor in Florida and happened to go to a local clinic that looked like a third world country: scores of people crammed into a waiting area, standing room only, screaming children, very ill adults. It was shocking. Turns out this clinic has been designated for use by Medicaid-type patients and they only take walk-ins, not appointments. They open at 5am for this (FIVE A.M.!!).

    Now who in their right mind would suffer through that when all you have to do is show up at our local lovely modern shiny ER and get almost-immediate service?

  44. MD as HELL –

    I don’t have any problem with copay for ER care. Indeed, I think most, if not all, insurance plans being sold on the new exchanges require copays to use the ER. The problem, I think, is that assuming the hospitals cannot insist on collecting it at the point of service, they may never collect it from people who don’t have a credit card or a debit card or much cash.

    As I understand it, patients entering the ER are triaged and assigned a code of 1 to 5 based on how severe their medical issue is and how urgently they need care. If it were possible to track ER use, people who come in often for minor problems could be subject to some sort of sanctions though I’m not sure how to do that. In Taiwan, excessive users of the healthcare system get a talking to by someone in authority. Maybe we could try something similar.

  45. Colin, thanks for your response.

    If a large study failed to show that stents (very costly) improved cardiovascular outcomes over medications (far cheaper), I doubt we would be discussing the nuances of hypothesis testing.

    For a program that costs $450 billion a year, which is being expanded, and which will have a tab of $ 7 trillion over 10 years, failure to show a difference with statistical significance is significant.

    I would suggest a Bayesian rather than a frequentist approach. What were your priors (minus post hoc adjustment)? Did the results change them? Can your priors ever be changed?

    I expected Medicaid to move the dial, not just be a safety net. Many believe it should just be a safety net, which is fine, but there are cheaper ways of providing the same safety net and using the difference for other forms of public investment.

  46. “If all the raindrops were lemondrops and gumdrops, oh what a world it would be.”

    Never going to happen because EMS only transports to an ER.

    To get the Medicaid populaton out of the ER you need to make them have an ER copay and not a primary care co-pay, instead of the way it is now.

    Studying controlled groups of poor people, one with free healthcare and one with prudent as needed healthcare, has not been done.

  47. 1. Thanks for the piece. These studies are really interesting and come as close to testing certain policy assumptions as any studies that I can remember.

    2. People have overreacted to these studies as far as how important they are for Obamacare. Sarah Kliff has a good piece about how we should be measuring success/failure for that program: http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/02/four-ways-to-tell-if-obamacare-is-working/

    3. “Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.”

    You accepted a null hypothesis here, which is fallacious under null hypothesis significance testing. Remember that failure to demonstrate a difference is NOT the same is demonstrating no difference. This is a subtle but critical statistical difference, as in the population, these two means are not the same (literally a probability of zero). See here for more information: http://liesandstats.wordpress.com/2008/09/08/accept-the-null-hypothesis-or-fail-to-reject-it/

  48. “The Medicaid population goes to the ER at the drop of a hat, placing them in the crosshairs of the well-intentioned but very dangerous healthcare system.”

    I’m told that the Medicaid population views ER care as better care than either primary care that they may have access to or care from providers at a community health clinic. I think a good part of the reason for this is that the ER is seen as a one stop shop. If they need imaging or blood work, they can get it on the spot. They don’t need to make another appointment with an imaging center or a lab which they may not be able to easily get to due to a lack of transportation and, if working, may lose pay if they need to take additional time off from the job.

    I think community health clinics staffed by salaried doctors and able to provide ER level services short of inpatient admission would likely serve this population better than a patient centered medical home. If inpatient admission is required, I’m sure the people at the clinic know how to call 911. Interoperable electronic medical records would also be helpful in allowing ER doctors and others to access the patient’s history.

    That all said, virtually all of the difference in life expectancy and infant mortality between the poor and the rest of the population is due to poverty and not the quality of healthcare they may have access to much of which may be unnecessary in the first place.

  49. The risk-adjusted outcomes of insured and Medicare patients are better (not in that study but others, see Roy’s book; v. easy read and lots of references).

    I would agree with you that it is fundamentally very difficult to accurately measure the quality of a healthcare system, as there are so many confounders.

    With Medicaid, the voices from the trenches seem to be echoing a deep structural problem.

    This, of course, does not mean that Medicaid should be abolished. Perhaps morph with Medicare?

  50. If, as you say, “The outcomes they used are bona fide health outcomes. The sort that are used to make comparisons between the US and, say, Sweden…” And US health care is found to be not providing value for the trillions spent, then aren’t you arguing that those on Medicaid are in fact receiving the exact same poor care every other insured person does?

  51. Shane, thanks for sharing experience. More voices from the trenches ought to be heard.

  52. Being based in Oregon I’ve had the pleasure of watching the development and failings of Oregon Medicaid from the inside.

    Yes, the reimbursements are horrible. The CCO that I am familiar with reimburses specialists at around 25% less than Medicare (which is even less when you remember that Oregon has some of the lowest Medicare rates in the US).

    Last year they switched to a highly managed care model with a huge amount of hoops put in place for Pre Auths and Referrals. Then the denial and constant medical necessity appeal process started. Five times as much work for less than a third of what a commercial patient pays. Many providers started restricted their schedules by necessity and limiting the number of Medicaid patients and some closed all together.

    Now some have wait lists of 4-5 months plus so where do they go? The ED which calls the lucky on call specialist in.

    The model in place is basically forcing the patients into harms way when it comes to their health.

    There are ways to fix it but that would mean the plans will have to trust, engage with and invest in the providers. Both the carrot and the stick are needed rather than stick, Stick, STICK……

    Their are some positives with the FQHC clinics but they need better management and support from the rest of the system…

    Happy New Year from Oregon…

  53. Indeed Perry. Quite agree.

    And running away from the realities that you have mentioned does disservice most to the recipients of the program.

  54. I would have to agree with you Saurabh, under Obamacare, Medicaid is an insurance program, not just a safety net. If this is true, and we are looking at outcomes as in Medicare, with the same set of requirements and mandates, the current fee schedule for providers is just not appropriate given the scope of problems these patients will have, and the amount of time and effort required for documentation and billing. Because of the significant socio-economic disadvantage many of these people will have,
    a “safety net” approach just won’t work. On the other hand, if you expend money and resources to improve the socioeconomic problems, then you can revert to a safety net approach.

  55. Fair enough, although I disagree.

    But it still begs the question whether there is not a cheaper way of providing the SAME safety net.

    I think we can answer this without descending in to the “how many angels can dance on the head of a pin” type of logical wizardry.

  56. Right, exactly. Moreover, had they just extended Medicare down to age 50, say, just as a “public option,” and allocated for Medicaid expansion for the poor and otherwise uninsured, problem essentially solved. No need for this ungainly Custerfluck HIX, CMS admin machinery already long in place.

    Medical UTIL is highly, highly correlated with age, hence the 50+ idea. The bigger ticket UTIL usually commences around 50. That the Dems could have passed this ACA POS but not a Medicare expansion, well, that dog just won’t hunt. It just wouldn’t have been the “Signature Accomplishment” that O may well come to rue.
    __

    Dr. Mike says “And all us docs are very glad you are not our patient.”

    Yeah, I’m REAL difficult. My long-time Primary’s name is Robert Gong, MD (Vegas, Internal Med 3-doc shop). Ask him how difficult I am.

    BTW: His shop was also one of my Meaningful Use clients. Got them attested Stage 1 Year 1 pronto despite their having upgraded way late. $54k easy money. Seek them out, ask them just how much trouble I was.

    Whatever.

    BTW: Full Disclosure. I am also Certified EHR vendor, http://ClinicMonkey.blogspot.com

    lol

  57. Medicaid IS a safety net program so I have no problem thinking of it as a safety net.

  58. You’ve just made a distinction without a difference.

    The outcomes they used are bona fide health outcomes. The sort that are used to make comparisons between the US and, say, Sweden when we wish to see whether the trillions spent is value for money.

    When these numbers tells us what we want to hear they are “health outcomes’ and when they don’t then they are “glycated hemoglobin and nothing else”.

    At an annual tab of $450 billion, I would expect a program to be more than just a safety net. Wouldn’t you?

  59. “Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance.”

    No, they didn’t find that. They did find “no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels… [and] no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher.”

    That’s it. That’s all they looked for they do not say Medicaid has no effects on all health outcomes. They also found “Medicaid coverage decreased the probability of a positive screening for depression (−9.15 percentage points; 95% confidence interval, −16.70 to −1.60; P=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.”

    All in all, no negative outcomes but some positive ones.

  60. We’re halfway to single payer already. Why not just scale up to finish the job?

  61. The people without coverage are much better off since they will avoid healthcare, which is very dangerous for the otherwise well who want to stay that way.

    The Medicaid population goes to the ER at the drop of a hat, placing them in the crosshairs of the well-intentioned but very dangerous healthcare system.

  62. Typical argumentum ad hominem.

    I have no objections to being called a Luddite, a cliched term that reflects poorly on those who use it. But my preference would be to be called a Cassandra, one who is cursed by the gods to tell the truth but never to be believed. And that means that EMRs are the new Trojan Horse, a bright shiny object that entrances the uninformed masses, but has something very nasty inside.

  63. Nope, just a brand new spankin EHR loaded w ICD 10 and advanced decision support, since doctors no longer have the intellect they once did. Hey, @ gladd, which vendor are you shilling for?

  64. For someone purporting to be a physician, you have a very low standard of “proof.” You cannot “prove” your broad-brush assertion. Moreover, the HIT evidence, while mixed, refute your Luddite claim.

    Glad you’re not my doctor.

  65. As do EMR cheerleaders, who so far have been proven wrong on everything they predicted.

  66. Bob –

    It’s actually about 70% of Medicaid dollars that are spent on the aged, blind and disabled (ABD) population. Medicaid spends over $100 billion annually for long term care alone. Home healthcare is another large expense. It also pays for roundly 40% of the 4 million births in the U.S. each year as well as for any very expensive care that might be required by any of those children born well before the normal term and with very low birth weight. Children 1 to 18 are relatively cheap to cover costing between $1,500 and $2,000 per year each on average. Healthy adults with no children but low income who were not previously eligible for Medicaid are also quite inexpensive to cover.

  67. EHRs will solve all of these problems because they make the doctors’ work so much more efficient!

  68. I believe that over two thirds of Medicaid expenditures are on behalf of elderly and disabiled beneficiaries.

    The ‘conventional health insurance’ part of Medicaid is drawing almost all the attention lately, and is worth debating on its own, but it is not the whole program.

  69. Most doctors would rather see the Medicaid patients for free than to deal with the morass of beauracracy to collect $15 for a visit.

    The Medicaid patients are different in many ways from those who go bare. They feel entitled whereas those w/o insurance fee appreciative.

  70. The natural design was the study’s strength as well, because it tested the effectiveness not just efficacy in a contrived situation.

    Your exception is noted, but in matters related to Medicaid, science and ideology are inseparable. On both sides of the political divide.

    This is the scourge of social science research: the flawed design becomes apparent when results don’t tally with belief. And design is (can) never be as good as the physical sciences. And why such studies seldom change people’s priors (minds).

  71. The experiment fell into their laps. The mix of patients and interventional design did not have an option menu.

    The investigators do speak on the same if you search around. Conspicuous absence may be too harsh–the ideological side of study dwarfed the scientific one.

    Be that as it may, I present the links above to offer additional insights. I am not looking to take sides and debate.

    Brad

  72. Happy new year Brad!

    Thanks for the link. Reasonable and well articulated explanations.

    However, one must be careful. There is a fine line between objective inference and post hoc rationalization .

    These nuances were conspicuous by their absence when the Oregon experiment release their early, more positive, results in 2011. And I very much doubt that we would be clamouring to find nuances if the results were incontrovertibly positive across the board.

    You can uncompromisingly support a program’s goal whilst questioning its mechanism of delivery. This is not a dichotomy.

  73. I think some form of decentralization is necessary. Debt forgiveness for seeing Medicaid patients is a great suggestion. Importantly, as no one really denies, the red tape must be reduced.

  74. The assumption of similarity comes from control of confounders such as health status, socioeconomic status, ethnicity and zip code. I would agree that this statistical exercise, though valuable, is not perfect.

    I recommend Avik Roy’s “How Medicaid Fails the Poor”. It’s a short read.

  75. The mere act of enrolling might be reflective of poor health. That’s a good point. Although studies controlled for health status, controlling for confounder is not perfect.

    Medicaid’s problem, from what I can surmise, is a problem of access because of poor reimbursement compounded by the regulatory burden.

    As for the definition of fraud… well I am still pinching myself to wake up.

  76. Several issues are at play here. First, the people who are on Medicaid are generally in low socio-economic status, which means efforts to improve their health are going to be complicated by difficulty with proper housing, food and support systems. This means these patients will be very complicated for doctors to treat. If a physician is spending significant time dealing with social problems in addition to complex medical problems, it becomes a farce to accept the minimal payment AND be expected to fill out all the appropriate forms, and complicated billing procedures. I suspect your physician friend was more willing to treat people for free just to circumvent all the idiotic documentation, plus she is probably covered under some element of “Good Samaritan” law for malpractice. I suspect there are many docs out there willing to forgo lousy payment and extensive documentation for just being able to help and treat patients for free.
    I always thought there could be several ways to handle this. The government could staff Medicaid clinics with doctors for reasonable hours and pay, and limit the amount of documentation to what is required for patient care, period. Heck, you could have a Health Service physician who has had medical training paid for by the government to repay by service to the underserved.
    The whole idea of the Patient Centered Medical Home is really quite appropriate for the Medicaid setting. If the government really wants to get in to medical care, it could fund clinics to take care of the indigent without dealing with this whole insurance debacle.

  77. Might not the converse of this argument be that people who are uninsured manage to obtain, through community health facilities and whatnot, care as adequate as that provided under Medicaid? Also, being “uninsured,” unlike enrollment in Medicaid, requires no affirmative act, which presupposes a perceived need for medical attention.

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