I’m going to cannabalize and tweak something I wrote for the Incidental Economist. I’m not sure this even needs a cite. It was near the bottom of a long post. No one may even know that it’s there.
People ask: Is Medicaid better or worse than private insurance in gaining access to needed care? I think it is difficult, and probably misplaced, to give a simple thumbs-up or thumbs-down answer to that broad question. One should give different answers for different people, who face different challenges in their access to medical and social services. Both Medicaid and private insurance have distinct advantages and challenges. Neither provides the reliable, practical access to proficient services vulnerable people really need.
I’ve been writing about that NEJM audit study of Cook County. That study showed that medical specialists turn away Medicaid patients with dismaying regularity.
In that study, patients faced serious but basic issues: A broken bone, diagnosing type I diabetes, and so on. Medicaid patients can’t get appointments with many specialists. They’ll frequent providers with grittier waiting rooms, maybe in grittier neighborhoods. Yet they can get reasonable no-frills access to safety-net providers who address these concerns. These providers also have genuine expertise in addressing the challenges people face in low-income communities. These providers are more likely to have strong connections to ancillary services their patients might need. They are less likely to hand their patients a costly non-generic prescription that will never be filled.
Medicaid may also compare favorably with low-cost, low-quality private insurers who serve many families of modest means. The NEJM study found that specialists were much more likely to turn away Medicaid recipients than they were to turn away those with Blue Cross Blue Shield (BCBS). Yet BCBS coverage is pretty costly. Cheaper plans offer more limited access through a narrower network of providers. These might not fare as well in audit studies.
In serving Medicaid recipients within traditional safety-net settings, a key policy challenge is to provide a financially sound infrastructure which ensures high-quality and dignified services within this network of care. In part because of health reform and the 2009 stimulus, some safety-net providers provide sophisticated, team-based care in which non-physicians make important contributions and in which electronic health records play a valuable role.
Medicaid is designed for patients with complex medical and social service needs. There is no genuine private-sector equivalent for many Medicaid services provided to disabled individuals with low incomes and various special needs. I’ll write more about this in a subsequent post. I’ll say right now that new efforts to create Medicaid medical homes hold promise in serving some of the most costly and challenging populations on the Medicaid rolls.
Medicaid is also designedâ€”and this is importantâ€“for patients who have no money. Suppose you are a low-income worker, and your daughter has a complicated cancer requiring $500,000 chemotherapy treatments. Your private insurance could easily impose crushing financial burdens. The Affordable Care Act makes great progress on this front through regulatory measures that limit out-of-pocket spending, rescissions, and more. Still, Medicaid would provide much better protection against medical bankruptcy than private insurers are likely to do.
My wife and I have encountered many issues caing for her dual-eligible, intellectually disabled brother. We have not faced financial difficulties related to his care, despite his multiple hospitalizations and his need for other costly medical interventions. Many policymakers seem to have lost sight of this basic point. When California, for example, stops paying for routine dental care for intellectually disabled people, how do they expect people to get their teeth cleaned or their cavities filled?
These are the strengths of Medicaid. Yet thinking back to that $500,000 cancer, you would probably want your child to receive excellent care from the best provider. If your mother experienced a heart problem or a strange diabetes complication, you would want her to receive care from the most technically proficient specialists. This weekâ€™s NEJM study suggests that this might be hard. Many specialists do not take Medicaid patients. Disparate access to technically proficient providers and hospitals means a lot to individual patients. It also matters at the population level, for example in explaining black-white health disparities.
Both private and public insurance face significant challenges. It isn’t easy to bring the right care to the right patient at the right time. It isn’t easy to raise the quality of safety-net providers or to promote more cost-effective care. The Affordable Care Act includes many provisions to pursue these goals. There’s a reason behind all those hundreds of pages.