Austin Frakt has penned a reply to a recent piece I wrote on Medicaid for my health-policy blog on Forbes, The Apothecary. Austin is a guy who takes the time to address opposing points of view, to his credit, and I’ve enjoyed my back-and-forth with him over time. But while I’m grateful for Austin’s attention to an issue of high import—the degree to which Medicaid harms the poor—he didn’t respond to the core concerns I raised in my post.
For those who haven’t been following the debate on Medicaid outcomes from the beginning, let me offer a brief summary.
How Medicaid Harms the Poor: The Debate (So Far)
Last summer, on my old blog, I put up a series of posts highlighting the findings of a study published in Annals of Surgery by a group of surgeons at the University of Virginia, entitled “Primary Payer Status Affects Mortality for Major Surgical Operations.” The study evaluated 893,658 major surgical operations occurring between 2003 and 2007, stratified by primary payer status, on three outcomes endpoints: in-hospital mortality, length of stay, and total costs incurred.
Despite the fact that the authors controlled for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid fared poorly compared to those with private insurance, Medicare, and even the uninsured. Relative to those with private insurance, Medicare, uninsured, and Medicaid patients were 45%, 74%, and 97% more likely to die in the hospital post-operatively. The average length of stay for private, Medicare, uninsured, and Medicaid patients was 7.38, 8.77, 7.01, and 10.49 days, respectively. Total costs per patient were $63,057, $69,408, $65.667, and $79,140 respectively.
Despite Austin’s initial criticism that this was merely one study, and therefore not representative, the poor performance of Medicaid beneficiaries is well-established in a very large body of medical literature. What was striking about the UVa study was its large sample size; that it controlled for a highly validated set of background health and social factors; and its finding that Medicaid beneficiaries not only underperformed those with private insurance (and dramatically so), but also those who lacked insurance.
Given that a core feature of PPACA is its large expansion of Medicaid to those with higher incomes than current beneficiaries, I argued that it was far from clear that this expansion would improve health outcomes, and in fact was likely to harm them by crowding out the more-efficacious private sector. Furthermore, I argued for the clinical benefits of migrating Medicaid over to a premium-support or cash-assistance model, which would allow Medicaid recipients to benefit from the superior quality of care delivered by private insurance. As I’ve said all along, “There is, doubtless, a level of poverty at which Medcaid is better than nothing at all. But most people can afford to take on more responsibility for their own care, and indeed would be far better off doing so.”