Today’s New England Journal of Medicine includes a nice audit study by Joanna Bisgaier and Karin Rhodes conducted here in Cook County. Between January and May 2010, research assistants called a stratified random sample outpatient medical specialty clinics. The calls followed a standard script. Each of these clinics received two phone calls, one month apart, from the same research assistant, who would pose as the mother of a child with a rather significant medical complaint who was seeking outpatient care.
There was one key difference between the two calls. In one of them, the RA stated that her child was insured by Medicaid or CHIP. In another call, the RA stated that her child was insured through Blue Cross-Blue Shield. (The state of Illinois provided dummy Medicaid identification numbers and other help to the study, in part to comply with a consent decree stemming from a class-action suit.)
At one level, the results speak for themselves. Wallet biopsies matter. Overall, 66% of the callers reporting public insurance coverage were denied appointments, compared with only 11% of those reporting private coverage. As shown below the fold for every speciality, publicly insured kids were much more likely to be denied appointments than were otherwise comparable patients with nice private coverage.
As is also shown below the fold, many of the presenting complaints were pretty serious: a child with possible type 1 diabetes seeking to see an endocrinologist, one with a possible forearm fracture seeking care from an orthopedist, and so on. When publicly-insured could get an appointment, on average they faced a longer wait as well.
Different hypotheses might explain these access disparities are less obvious. As in the old mystery Murder on the Orient Express, there are many suspects, and I suspect they are all at least somewhat guilty. Illinois’ Medicaid reimbursement rates are below market rates–a problem compounded by the state’s reputation for delayed payment and administrative hassles. For various other reasons, Medicaid recipients themselves face discrimination from providers, in part because of real or perceived reactions to these patients among more profitable patients.
The consequences of these patterns for patients are also unclear. Bisgaier and Rhodes provide further evidence that Cook County has a segmented medical system in which publicly-insured patients face constrained access to a range of medical specialists who prefer the privately insured. Studies such as this one do not address whether Medicaid-CHIP patients receive delayed care or worse care because they rely on a more limited range of specialty providers. Audit studies leave important questions unanswered.
Still, I hope that state and federal policymakers pay attention to the stark answers such studies do provide. Governors across the country now complain about the fiscal burden Medicaid imposes. Many in official Washington speak of the “entitlement crisis” as if Medicaid and Medicare raise similar dilemmas. This is misguided. Medical specialists argue and cajole policymakers in search of higher Medicare reimbursement rates. Sometimes these higher rates are justified. Many specialists don’t even bother to argue about Medicaid. They just don’t treat patients. The same is true of many hospitals.
I wish medical specialists behaved differently. Many of these specialties are quite lucrative. They can do better. Yet the market signal could hardly be clearer. If we want low-income people to have access to good medical care, Medicaid needs to pay for it. Right now it doesn’t, with predictable results.