The Wall Street Journal attacked the Affordable Care Act's (ACA) Medicaid expansion by claiming that Medicaid beneficiaries would have better health outcomes with no insurance at all. But the Journal's analysis relies on an inaccurate reading of an Oregon health care study and ignores that Medicaid has been shown to lower rates of depression, reduce financial strain, and benefits low-income children, mothers, and veterans.
Wall Street Journal Cherry-Picks Oregon Study To Attack Medicaid As A “National Disgrace”
Wall Street Journal Cited Oregon Study To Claim Medicaid Is “National Disgrace” That Will Not Improve Health Outcomes. A Wall Street Journal editorial claimed that the expansion of the Medicaid program under the Affordable Care Act (ACA) was a political move by Democrats that does nothing to help “the well-being of the poor,” claiming a study conducted in Oregon “concluded that the program generates no discernible improvement in health compared to being uninsured” :
In reality, Medicaid is now mostly a middle-class entitlement for nursing homes. Almost two-thirds of Medicaid spending flows to the elderly, and 60% of people in long-term care institutions are on the program.
Some 20% of the people under 65 who are eligible for the program today also haven't signed up. One reason might be the scandalously poor quality of care as states squeeze down provider reimbursements. Only this May an important randomized, controlled trial in Oregon concluded that the program generates no discernible improvement in health compared to being uninsured.
But the truth is that liberals view Medicaid as a national model, not a national disgrace. Coverage on ObamaCare's nominally private exchanges largely clones Medicaid's narrow networks of doctors and hospitals, low reimbursements, limited patient choice and heavy federal regulation. It might be more accurate to call it Obamacaid. [The Wall Street Journal, 10/8/13, emphasis added]
Oregon Study Shows Medicaid Provided Many Health Benefits
Oregon Study Found Medicaid Coverage Provided Many Health Benefits, Including Better Diabetes Detection And Lower Rates Of Depression. A study of Medicaid's clinical outcomes in Oregon found that Medicaid coverage “did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain” :
This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain. [The New England Journal of Medicine, 5/2/13]
Wash. Post's Ezra Klein: Oregon Study Showed Medicaid Program Expanded Care, Worked Effectively As A Health Insurance Program. According to The Washington Post's Ezra Klein, the study proved that “Medicaid works as health insurance” because Oregon residents who were randomly given Medicaid coverage “got much more health care ... than the residents who lost it” :
Here's what we can say with certainty: Medicaid works as health insurance.
That might seem obvious. It's actually not. A big criticism of Medicaid is that it pays doctors so little that it's essentially worthless because no doctor will see you. But the Oregon residents who won the Medicaid lottery got much more health care -- including preventive health care -- than the residents who lost it. They also saw catastrophic health costs basically vanish.
So here's what happened in the first two years of the Oregon Medicaid experiment: Medicaid proved itself good health insurance. The people who got Medicaid used more health care, and seem to have done so smartly -- they got preventive care, they got their diabetes diagnosed and began managing it, treated their depression, and so on. But the health care itself didn't work as well as we hoped -- at least not in terms of cutting rates of hypertension and cholesterol. [The Washington Post, Wonkblog, 5/2/13]
Kaiser President Drew Altman: Pundits Misrepresented Oregon Health Care Study, Which “Confirmed Significant Improvements Among The Adults Who Gained Medicaid Coverage.” Writing in The New York Times, Kaiser Family Foundation President Drew Altman said critics who used the Oregon study to claim individuals would do better without insurance were misrepresenting the evidence:
Bottom line: if you were a middle class family with private insurance and your spouse's cholesterol count or blood pressure had not improved in a two year period, would you want to go without insurance protection altogether? If you were a single adult making $15,000 a year or less, would you feel comfortable with a catastrophic coverage plan with a deductible of several thousand dollars a year?
You would do neither of these things, but these are the recommendations several pundits seem to think make sense for low income people based on their reading of the Oregon Medicaid experiment.
Two years out from the start of the experiment, the Oregon study has confirmed significant improvements among the adults who gained Medicaid coverage. Findings of particular importance include greater probability of receiving diagnosis of diabetes and use of medication for diabetes; 30 percent relative reduction in rate of depression; increased visits, prescription drugs, and use of many preventive services, and the near elimination of catastrophic out-of-pocket medical expenses.
Insurance -- public or private -- provides financial protection and access to medical care which low-income people need just as everybody else does. But it cannot by itself change behavior, alleviate poverty, or guarantee that the medical system is doing all it can to improve health. [The New York Times, 5/6/13]
Medicaid Expansion Will Help Insure Low-Income Families
Centers For Medicare & Medicaid Services: Medicaid Expansion Benefits Individuals With Income Below 133 Percent Of The Poverty Line. According to the Centers for Medicare & Medicaid Services' website, the ACA's Medicaid expansion affects “individuals under 65 years of age with income below 133 percent of the federal poverty level” :
The Affordable Care Act fills in current gaps in coverage for the poorest Americans by creating a minimum Medicaid income eligibility level across the country. Beginning in January 2014, individuals under 65 years of age with income below 133 percent of the federal poverty level (FPL) will be eligible for Medicaid. [Medicaid.gov, accessed 10/9/13]
Kaiser Health: “In States That Expand Medicaid, Many Low-Income Parents And Other Adults Will Become Newly Eligible For Coverage.” The Kaiser Commission on Medicaid and the Uninsured explained that low-income parents will become newly eligible for coverage under the Medicaid expansion, but that in states that do not expand coverage to adults who make under 138 percent of the poverty line (under the new methodology of calculating income under the Affordable Care Act), poor adults will still face coverage gaps:
In states that expand Medicaid, many low-income parents and other adults will become newly eligible for coverage. Overall, the median eligibility limit for parents in the 25 states moving forward with the Medicaid expansion will rise from 106% FPL to 138% FPL for parents and from 0% to 138% FPL for childless adults (Figure 1). However, the scope of changes for these groups varies widely across the states. Overall, eligibility levels will increase for parents in 18 states and for childless adults in 23 states. The remaining states in this group had already expanded Medicaid to higher incomes. These states will either maintain higher eligiblity levels or reduce eligibility to 138% FPL. In states reducing Medicaid eligibility, those losing Medicaid coverage would have incomes that would qualify for federal subsidies to help pay for Marketplace coverage.
In states that do not expand Medicaid, significant coverage gaps will remain for many poor adults. In the 26 states not currently moving forward with the Medicaid expansion, adults between the January 2014 Medicaid eligibility limits and 100% FPL will not gain a coverage option. These adults will not be eligible for Medicaid or the federal subsidies to help pay for Marketplace coverage. As of January 2014, 22 states will have Medicaid eligibility levels for parents below 100% FPL (Figure 2). Moreover, in all of these states, childless adults will remain ineligible for full Medicaid coverage regardless of how low their income levels are. [Kaiser Commission On Medicaid and the Uninsured, October 2013, emphasis original; American Public Health Association, accessed 10/9/13, emphasis original]
NYT: 8 Million Impoverished Americans Will Be Uninsured Because States Failed To Participate In The Medicaid Expansion. The New York Times reported that because some states did not expand Medicaid, eight million Americans “are impoverished, uninsured and ineligible for help” :
Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.
Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.
The 26 states that have rejected the Medicaid expansion are home to about half of the country's population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country's uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses' aides.
The states that did not expand Medicaid have less generous safety nets: For adults with children, the median income limit for Medicaid is just under half of the federal poverty level -- or about $5,600 a year for an individual -- while in states that are expanding, it is above the poverty line, or about $12,200, according to the Kaiser Family Foundation. There is little or no coverage of childless adults in the states not expanding, Kaiser said. [The New York Times, 10/2/13]
Medicaid Improves Health Care For Low-Income Children, Mothers, And Veterans
Center On Budget And Policy Priorities: Expanding Medicaid Coverage For Low-Income Parents Benefits Children. The Center on Budget and Policy Priorities (CBPP) collected research on how expanded health coverage for low-income parents affects children. Though Medicaid's Children's Health Insurance Program (CHIP) has led to “tremendous progress ... in lowering the number of uninsured children,” CBPP noted that “the number of uninsured parents remains high,” which, studies show, has an effect on children's well-being:
Covering parents means that more eligible children will enroll. Low-income families with uninsured parents are three times as likely to have eligible but uninsured children as families with parents covered by private insurance or Medicaid. Previous expansions of Medicaid coverage for parents have led to a significant increase in enrollment of eligible children and a drop in the number of uninsured children.
Covering parents means that children are more likely to stay enrolled. Studies have found that covering parents makes it less likely that children experience breaks in their own Medicaid and CHIP coverage and remain insured.
Covering parents makes it more likely that children receive needed care like preventive care and other health care services. Studies have found that insured children whose parents are also insured are more likely to receive check-ups and other care, compared to insured children whose parents are uninsured.
Parents' health can affect children's health and well-being. The Institute of Medicine has reported that a parent's poor physical or mental health can contribute to a stressful family environment that may impair the health or well-being of a child. Moreover, uninsured parents who can't get care may be unable to work or may end up with big medical bills when they do get care. In either case, the financial consequences have a big impact on children even if the children have coverage. [The Center on Budget and Policy Priorities, accessed 10/9/13, emphasis original]
CBPP: Medicaid Improves Health Outcomes And Lowers Costs For Patients With HIV. An October 2012 fact sheet from the CBPP noted that expanded access to Medicaid would help individuals with HIV access early treatment, and reduce their long-term health costs:
Adopting health reform's Medicaid expansion would allow uninsured adults with HIV to receive needed care while saving states money. Medicaid is the largest source of health care coverage for people with HIV, covering approximately a quarter of the 1.1 million Americans with HIV.
As noted, today, individuals with HIV typically qualify for Medicaid only when they are disabled or they have been diagnosed with AIDS. But that is when treatment is the most costly. Research shows that it costs 2.6 times as much to treat someone with AIDS as it does to treat someone earlier in the course of the HIV disease.
States that adopt the Medicaid expansion will provide people with HIV better access to early and continuous treatment, often in the form of antiretroviral drugs. Providing access to continuous coverage has been shown to significantly reduce the risk of further transmission and delay progression to more debilitating and costlier stages of the virus. [The Center on Budget and Policy Priorities, 10/11/12]
Kaiser Commission On Medicaid And The Uninsured: “Compared To Low-Income Uninsured Children, Children Enrolled In Medicaid Are Significantly More Likely” To Receive Care. According to the Kaiser Commission on Medicaid and the Uninsured, "[h]aving Medicaid is much better than being uninsured" and “compared to low-income uninsured children, children enrolled in Medicaid are significantly more likely to have a usual source of care” :
Having Medicaid is much better than being uninsured.
Consistently, research indicates that people with Medicaid coverage fare much better than their uninsured counterparts on diverse measures of access to care, utilization, and unmet need. A large body of evidence shows that, compared to low-income uninsured children, children enrolled in Medicaid are significantly more likely to have a usual source of care (USOC) and to receive well-child care, and significantly less likely to have unmet or delayed needs for medical care, dental care, and prescription drugs due to costs.
The research findings on adults generally mirror the patterns for children. [Kaiser Commission on Medicaid and the Uninsured, 8/2/13, emphasis original]
CBPP: Full Medicaid Expansion Would Insure Nearly Half Of Uninsured Veterans. CBPP cited an Urban Institute report which found that if all states expanded their Medicaid coverage in accordance with the ACA, “nearly half of the nation's uninsured veterans would gain a pathway to affordable health care coverage” :
If all states expand their Medicaid programs in 2014, nearly half of the nation's uninsured veterans would gain a pathway to affordable health care coverage. According to an Urban Institute report, 10 percent of the nation's 12.5 million non-elderly veterans do not have health coverage. Nearly half of uninsured veterans have incomes below 138 percent of the poverty line, which would make them eligible for Medicaid if their states choose to adopt health reform's Medicaid expansion. Another 40 percent of uninsured veterans (with incomes up to 400 percent of the poverty line) will likely qualify for subsidized exchange coverage. [The Center on Budget and Policy Priorities, 10/11/12]
CBPP: Expanding Medicaid Coverage Improves Health Outcomes For Mothers And Babies. According to a CBPP fact sheet, Medicaid already “plays a central role in maternity services,” but limits coverage for low-income mothers during and after pregnancy. The fact sheet noted expanded care for women “decreases their own health risks and makes it more likely that their babies will be born healthy” :
Medicaid plays a central role in maternity services, covering more than 40 percent of births nationwide and more than 60 percent of births in Arkansas, Louisiana, Mississippi, South Carolina, Texas, and West Virginia.
Medicaid also covers 53 percent of hospital stays for infants born prematurely or with a low birth weight, and 45 percent of hospital stays due to birth defects.
However, many low-income women are only eligible for Medicaid while they are pregnant and for a short period of time afterwards under current Medicaid eligibility rules. In the typical state, women with family incomes up to 185 percent of the poverty line (about $21,000 a year for an individual and $36,000 for a family of three) are eligible for Medicaid when they are pregnant and for 60 days after giving birth.
Expanding Medicaid would provide health coverage to low-income women irrespective of whether they are pregnant, resulting in better outcomes for both the women who gain coverage and the children they have in the future. Health coverage during the period before pregnancy allows women to receive preventive care like regular doctor visits, birth control, information about making healthy food choices, tobacco cessation programs, and substance abuse services that decreases their own health risks and makes it more likely that their babies will be born healthy if and when they become pregnant. For example, research shows that prenatal care for high-risk pregnant women reduces the incidence of costly premature births. [The Center on Budget and Policy Priorities, 4/17/13]
Former Director Of The Illinois Department Of Public Health: Medicaid Reduces Financial Strain And Improves Mental Health. In a May 2 Health Affairs blog post, Dr. John Lumpkin, former director of the Illinois Department of Public Health, reported that Medicaid has been shown “to substantially reduce depression” and lessen patients financial strain:
The study in NEJM highlighted the latest data from the experiment. It showed that enrollment in Medicaid, after about two years, profoundly increased patients' use of needed medical services, and vastly reduced the financial strain that previously limited their care.
The use of physician services, prescription drugs and hospitalizations increased by about 35 percent when patients had Medicaid. The probability of having a consistent place to get care, and to receive preventive services and screenings, increased by 50 percent or more.
Having Medicaid had a big impact on family finances. It virtually eliminated out-of-pocket catastrophic medical expenditures for enrolled individuals. It alleviated other measures of financial strain, such as reducing by more than 50 percent the probability of having to borrow money, or having to skip paying other bills because of medical expenses.
One of the most significant findings is that expanding Medicaid was shown to substantially reduce depression. Those who received Medicaid in the Oregon lottery reduced rates of depression by a noteworthy 30 percent compared to those who did not have coverage. This is important, because improving mental health is a powerful gateway to improving overall health.
Each of these factors demonstrates the value of health insurance coverage, but the study's findings show that coverage alone will not necessarily lead to good health. Over two years, those who received Medicaid through the lottery were more likely to be diagnosed with diabetes than those who were uninsured, but their blood sugar levels remained about the same. The same was true for their blood pressure and cholesterol levels. [Health Affairs Blog, 5/2/13]
ACA Increases Doctors' Medicaid Reimbursements
Washington Post: The ACA Will Aim To Expand Access To Doctors By Increasing Medicaid Reimbursement Rates. According to a February 8 Washington Post Wonkblog post, the ACA will address doctors' concerns by increasing provider reimbursement rates:
The health-care law's big attempt at increasing Medicaid access takes on the exact same factor that we think inhibits access: Low reimbursement rates. The Affordable Care Act boosts Medicaid primary care reimbursement rates to match those paid by the Medicare program. Given that Medicaid rates tend to be really low, this works out to an average raise of 73 percent.
In the states that have been paying the lowest rates, the increase is even bigger.
Does that matter on the ground, to providers? It's hard to know from most of the Medicaid research, which was conducted before the Affordable Care Act expanded Medicaid. We do have one study though, from Michigan, which suggests that most doctors do feel like they can take on more Medicaid patients than they currently see. [The Washington Post, 2/8/13]
Georgetown Health Policy Institute: Medicaid Reimbursement Rates Will Increase To At Least 100 Percent Of Medicare Rates. A Georgetown University Health Policy Institute blog explained that because of the ACA, “Medicaid reimbursement rates will increase to at least 100% of Medicare rates in the 2013 and 2014 calendar years” :
Thanks to the Affordable Care Act, Medicaid reimbursement rates will increase to at least 100% of Medicare rates in the 2013 and 2014 calendar years. The federal government will fund 100% of the difference in cost between what a state's Medicaid rate was on July 1, 2009 and the applicable Medicare rate.
It is estimated that Medicaid fees will increase by an average of 73% in 2013, but the impact will vary among states. For example, six states (California, Florida, Michigan, New Jersey, New York, and Rhode Island) will more than double their current rates, while nine states will have fee increases of less than 25%. Only two states (Alaska and North Dakota) will not be impacted, as their Medicaid fees are already above Medicare levels. [Georgetown University Health Policy Institute, Children's Health Policy Blog, 12/18/12]