Aaron Carroll and Austin Frakt have an excellent piece asking the question if people on Medicaid would be better off than people on private insurance.
is having Medicaid, as those critics also say, much worse than having private insurance?
…it’s far from proven that Medicaid is worse than private insurance. A lot depends on what kind of insurance is compared with Medicaid, and how they are compared.
a decades-old trial that looked at varying levels of cost-sharing: the RAND Health Insurance Experiment. This is relevant because one substantial difference between Medicaid and most private coverage is the level of cost-sharing. Medicaid is nearly free. Most private coverage comes with deductibles and co-payments.
The RAND study randomly assigned 2,750 families to one of four health plans. One had no cost-sharing whatsoever — kind of like Medicaid. The other three had cost-sharing (money people had to pay out-of-pocket for care) at levels of 25, 50 or 95 percent — capped at $1,000 at the time, which is about an inflation-adjusted $6,000 today…. In the RAND study, poorer and sicker people — exactly the kind more likely to be on Medicaid — were slightly more likely to die with cost-sharing.
Free care also resulted in improvements in vision and blood pressure for those with low income. As an influential 1983 New England Journal of Medicine paper put it: “Free care does make a difference.”
I want to focus on something a little different; service delivery models have changed dramatically. Medicaid Managed Care Organizations (MCO) are the dominant payers in Medicaid. Here the state pays an insurer to take care of a population and if the insurer can cover that population for less than the fixed fee, they profit. If not, they lose money. This leads to an alignment of incentives similar to fully insured private market coverage.
This has a major pragmatic challenge to the idea that Medicaid is systemically different than private individual market insurance.
I worked at UPMC Health Plan. UPMC Health Plan is a major MCO. It also has a significant Exchange/Individual market segment. My last three years at UPMC had me focused heavily on Medicaid. We sat on the west side of the 9th Floor. The Exchange folks sat on the east side of the 9th floor.
We used the same IT Department on the 14th Floor. We used the same call center on the 23rd Floor. Exchange dedicated member reps were in a small cluster at the arena side triangle while Medicaid dedicated reps were on the fountain side of the building. We used the same claim system. The Exchange and Medicaid teams frequently got together to lament the slow pace of upgrades to the claims system. We used the same stratification system although I think the algorithms that I designed were better and tighter than the ones that the Exchange team used. We used the same pharmacy benefit manager. They had a couple of minor tweaks to the software infrastructure that Medicaid did not need. We had a few tweaks that were specific to us. They answered to a different set of regulators than the Medicaid team.
The Medicaid network was far larger and more comprehensive than the networks that were attached to the most commonly sold Exchange plans. The Medicaid network was most of Western Pennsylvania hospitals with the exception of hospitals owned by a strategic competitor (AHN). The popular exchange networks were either narrow(Select) or super-narrow (Partners) networks. The Medicaid population is fairly transient in eligibility for most benefit groups as people would earn up and off to Exchange or come in from losing employer sponsored coverage. The Exchange population is fairly transient as people lost income and moved to Medicaid, people got new jobs with insurance and people switched year over year as better deals emerged.
There were four major differences in the products that were offered. Medicaid had minimal cost sharing. Exchange plans had cost sharing. It ranged from a little to a lot. Medicaid offered a single benefit design. UPMC Exchange offered 25+ benefit designs for the zip code where I previously lived. The Exchange team had spiffy looking ID cards that drove a former co-worker to tears as the ID card vendor was not useful for months on end. And finally, the Medicaid team consistently had to be profitable to cover the losses incurred by the Exchange team.
If we are in a universe of Medicaid managed care being the dominant delivery mechanism and most of the MCOs run multiple lines of business like UPMC does, I have a hard time seeing how the internal dynamics of care coordination, utilization management and business processes dramatically differ between Medicaid and individual market private insurance. The biggest difference is the price per unit of care purchased. But the operational differences from an insurer’s POV should not be significant as the insurer faces the same incentive structure of minimizing avoidable costs and driving down utilization whether or not the person’s ID card says “Medicaid” or “Exchange”.
** As a side note, there has to be one hell of an interesting study using the Arkansas Private Option data. People in Arkansas who qualify for Medicaid Expansion mostly were put on private exchange plans but there were scenarios where they could be moved over to Legacy Medicaid and then move back.
rikyrah
The only muthaphuckas that push the line that Medicaid is worse than private insurance..
are muthaphuckas that never wanted poor people to even have Medicaid..
TO.A.ONE.
Major Major Major Major
@rikyrah: Hell, they push a flawed interpretation of that lousy study showing that Medicaid is worse than no insurance all the time.
Bradley Flansbaum
But you are leaving out the critical component: the provider aspect. At UPMC and surrounding territory, the clinical care, specialty access, and facility quality may match the back office experience. Excellent. Fast forward to Boston, NYC, Philly, and other large metro areas–and you will find good care, but in circa 1960-70s clinics, long waits for derm, surg subspecialty, etc., and lesser patient experience. What the patient sees does not mirror the same kind of organizational excellence you describe on the admin side.
Ohio Mom
Tl;dr. Actually, I cannot bear reading anymore on this. Once again I’ll point out that one thing Medicaid does that private insurance doesn’t is provide adults with disabilities with funding for supervised living and other needed supports.
I just left a couple of messages at the Portman offices that aren’t busy or have full mailboxes, and I wrote an email for good measure.
David Anderson
@Bradley Flansbaum: Given the subsidy structure of the ACA and the BCRA, the least expensive Exchange plans in the markets you raise will have networks that look a lot like Medicaid networks (see Chicago, see Indianapolis right now)
NCSteve
This is the kind of thing that gives me that “this must be what going mad feels like” feeling.
The thing that makes you eligible for Medicaid is that you can’t afford to pay any goddamned cost sharing. It’s like saying poor people would be better off on a diet of sun-dried tomatoes, Parmesan-Reggiano, artichoke hearts and almond milk
Sab
@Ohio Mom: Thanks for the reminder.I’ll call again.
Ohio Mom
@Sab: I finally got through to the Cleveland office. But that could have been a lucky fluke.
In a way, I don’t blame them for avoiding the phone, it must be one harangue after another. Not that they don’t deserve it.
KithKanan
@David Anderson: See pretty much the entire state of California, Kaiser possibly excepted.
David Anderson
@KithKanan: including Kaiser as Kaiser would have to get their cost structure down to look like Medicaid(ish) plans to get healthy membership from a lightly subsidized individual market for poor people.
d58826
MORE on Trumpcare from Andy Slavett
long tweet.
one item
This isn’t putting the fox in the hen house, this is moving the entire fox family, mom, dad and the kids into the hen house. We are going to give this power to a critter who give Der Fuhrer a run for his money in corruption and self dealing.
https://twitter.com/ASlavitt/status/885617495218024448
Yarrow
@d58826:
Thanks for the link. From the thread:
Sorry, forgot this follow on tweet in the thread:
Hey, rich people. Have some Medicaid money!
jacy
Anecdotal experience: I have been on both Medicaid and a good Silver plan from Blue Cross in the past three years, and I have major medical issues that require ongoing treatment, including counseling for depression and anxiety. For me, there was no difference in care — same doctors, same tests, same medications, same therapists. The only difference (other than cost to me, which was not much of a difference when all was said and done) was there seemed to be less paperwork on my end with Medicaid.
d58826
@Yarrow: And the corruption is so obvious.
Yarrow
@jacy: Hope you are doing okay. Been thinking about you and how stressful this healthcare fight is given all your health issues.
I have not yet called my Senators but it’s next on my agenda today. I called yesterday and cried on the phone to the intern who answered. He didn’t know what to do. He kept trying to say it wasn’t as bad as I was saying. I asked him if he had any family members, friends, or other loved ones who had ever had a disease like cancer or diabetes or RA or some chronic condition and how he felt about taking away their coverage. How could the Senator do this. The Republicans promised they were going to fix things. How could they do this to us. More crying, tears. Poor kid didn’t know what to say. I told him he should think twice about working for someone who was going to take away health coverage from people and kill people as a result.
Brachiator
The more I read about the Senate bill, the more it appears to be a deliberate move to restore the status quo before Obamacare, with a few items to actually increase the perks which health insurance companies currently enjoy, with a few sops to placate the public (pre-existing conditions, the opiod problem). And oh, yeh, kill Medicaid expansion deader than dead. Nowhere is there any desire to replace Obamacare with anything better.
jacy
@Yarrow:
I’m actually doing pretty good! Turned out my thyroid was way underactive (we think due to the fact that chemotherapy did something wonky to my parathyroid, necessitating the removal of 90% of it), and I’ve been on synthetic thyroid for two months now along with going back to daily Welbutrin for mood disorders. That has improved my depression and physical symptoms, and I’m back to weekly counseling for anxiety. And so I’m more productive and in better shape physically than I have been since this whole thing started — which just emphasizes how important access to medical care is. Without it, many people’s lives would be unbearable or unlivable. I know mine would be.
Major Major Major Major
@jacy: that’s great, I know from some friends that treatment for hypothyroidism can really improve things.
Yarrow
@jacy: Glad to hear it. It’s crazy how much the thyroid affects things. I’ve had some problems with mine–nothing as bad as yours, though–and felt awful. Glad yours was found and treated.
It is so important that people can access medical care. It makes such a difference in how people can function in their daily lives. Not that Republicans care. Either you’re healthy or you should die. They’re pretty clear about that.
hedgehog the occasional commenter
Made my calls this morning; Gardner’s (R-Weasel) of course went right to voicemail. Going to follow it up with FaxZero.
Called Bennet’s office; got a staffer, asked her to thank Bennet for standing up for Coloradans, and (sort of tongue in cheek) asked her if the Senator could track Cory down, since we don’t seem to be having much luck? She sort-of laughed and said Bennet’s trying to get through.
@yarrow–hugs, if it helps. I have family with diabetes and Parkinson’s.
Yarrow
@hedgehog the occasional commenter: Thanks. I’m calling for myself and my family and a whole bunch of other people I know who will be screwed if this passes. Hell, we’ll all be screwed, even those people with “good” insurance through employers. If this two-tier system goes through the rich will be even better off and lower level employees will be worse off. Not to mention taking away coverage for things like pregnancy that will affect a wide swath of the country. It’s just appalling.
Like I said above, Republicans want you healthy or dead. No in between. Republicans = party of death.
Redshift
@Brachiator:
Not just Medicaid expansion, Medicaid itself.
Paul Krugman had a great post yesterday detailing how brazenly dishonest all the complaints Republicans ran on about problems with the current healthcare system, because their ideology would make all of them worse.
amygdala
@jacy: Medicaid varies a lot by state, so it depends where you are. I spent nearly all my career in NY and CA, where Medicaid has some serious gaps. A surgeon friend moved from CA to the Midwest and was astonished at how much better services were for Medicaid patients. He’s far from being touchy-feely, and is pretty conservative politically, but said it was such a relief just to be able to take care of people and not to have to factor in their insurance into coming up with a plan as much as he did in CA.
CA’s larger cities and NYC have public health systems that pick up some of the slack. Medicaid patients may not be able to get in to see a private doc in some specialties, but if they’re near a public teaching hospital, they can be seen there, if often by a resident or fellow supervised by faculty.
You know what’s rather good coverage, better than a lot of private insurance? The so-called dual eligibles, people who are on Medicaid and Medicare. Relatively few network issues, decent access to most drugs, and long-term coverage, too. I’ve seen Republicans get enraged about it. Rather than asking why the system can’t be improved to make that possible for everyone, they’d rather kick the poor.
Our patchwork system generates so many problems and exists because health coverage insecurity seems coded in American DNA for some reason. It sucks.
Betsy
@jacy: Thank you for sharing that experience. It helps me understand. If I had to describe my (non-)understanding, I would probably say I have always just sort of assumed in the back of my mind that Medicaid was a difficult, bureaucratic, and/or chintzy program to be on. Probably absorbed that message from the atmosphere of unreliable sources. Anyway, yours is a point of information from reality, so thanks.
The Moar You Know
@Betsy: You’ve got it confused with Kaiser. Understandable.
rikyrah
@Yarrow:
THAT’S WHO THEY ARE.
rikyrah
@d58826:
Slavitt has been a jewel. A Prince during this entire process.
rikyrah
@Brachiator:
Of course not.
jacy
@Betsy:
I’m in Louisiana, which just underwent Medicaid expansion a year ago this month — without that expansion, I would have been ineligible (I made just enough money for a while to fall into the “Jindal Hole.”) So I had 8 months on Medicaid. I was fortunate that all of my docs (primary care, oncologist, endocrinologist) accept Medicaid, so I didn’t have to do a thing but inform them that my insurance had changed. And I don’t know for a fact, but I was given the impression that putting in a request for testing is much simpler and less likely to be questioned through Medicaid than through private insurance. So, say, if my oncologist decided I needed to have an MRI, my private insurance might slow-walk it or ask for further documentation, or whatever, but through Medicaid, it’s much simpler. And it was much easier to get my counseling — again, just making sure Medicaid was accepted with my therapist. So in the past four years, I’ve had no insurance, a bare-bones catastrophic plan with a HUGE deductible ($6,000), a really good Silver plan with a $200 deductible, and Medicaid. The easiest to deal with was Medicaid, followed by the Silver plan. The catastrophic was a nightmare, because they argued every freaking penny. I’m still getting refunds from what they screwed up three years ago. But the care I have received under the Blue Cross Silver and Medicaid was, in the end, NO DIFFERENT.
Betsy
@Yarrow: The thing I have been most struck by in this whole health care fiasco is the notion that pregnancy and prenatal care is somehow an aspect of healthcare that only applies to a “subset” of the population.
Last time I checked, every single person who has ever lived was of woman born.
Pregnancy, therefore, is the ultimate – perhaps the *only* truly — universally applicable condition.
Prenatal care, by definition, is probably the only coverage component that would actually apply *completely universally, without exception,* to all covered people.
I mean, some people are born without certain organs, so even heart care, or stomach coverage, or toe coverage, or whatever, would not be truly universal.
But no person ever occurs without being prenatal!
Remarkable that Republicans can eyewash this into some kind of “women’s issue”.
David?
Brachiator
@rikyrah: RE: Nowhere is there any desire to replace Obamacare with anything better.
Here in Southern Cal, I keep hearing true believers (and Obama haters) waiting for Trump and the Republicans to save them. It’s almost sad. But the self-delusion is wrapped up into too much anger and stupidity.
d58826
@Betsy:
And what I have been most amazed by is for a group of people who will pull out a Bible faster than the Constitution and who never miss an opportunity to lift their voice in prayer to baby Jebess, sure seem to have a lot of passages missing from their Bibles. Like ‘that which you do to the least of my children’ and ‘do unto others’. These folks would have been on the side of the Romans on Good Friday.
TenguPhule
@NCSteve:
No, its worse.
Its staying sane while the world goes mad around you.
TenguPhule
@Betsy:
Only the rich will be able to afford healthy babies.
Everyone else must simply take their chances.
It is the Republican way.
hedgehog the occasional commenter
@rikyrah: @yarrow: Yes, to both of you,. And Dems need to be screaming this from the rooftops. (A point to add next time I call Bennet.)
rikyrah
Average age of U.S. Senator is 62. None would buy health insurance lacking these benefits. So why is it okay for their constituents? pic.twitter.com/bGfsN82hjv
— Chris Lu (@ChrisLu44) June 22, 2017
rikyrah
Hard to see but Capitol police encircling the scrum on both sides as Barber decries a bill of “political murder” against the poor pic.twitter.com/0ujTXEvdqP
— Jeff Stein (@JStein_Vox) July 13, 2017
Yarrow
Just called my Senators. No one answered phones. Mailboxes full. I started calling local offices and finally got someone for each of them. Profoundly disinterested in what I had to say. “I’ve noted your concern and zip code.”
I think I’ll call my Dem rep’s office to make myself feel better. Someone always answers the phones there.
rikyrah
Long line of Capitol Police getting in position to arrest Rev. Barber, rabbis, pastors after reading out warnings over bullhorn pic.twitter.com/xRjSDAzhlr
— Jeff Stein (@JStein_Vox) July 13, 2017
rikyrah
Rev. T. Anthony Spearman, 66, came from Greensboro NC. Said he’s thinking of a mom in his congregation w/ heart condition saved by ACA pic.twitter.com/3dsCXOCAnF
— Jeff Stein (@JStein_Vox) July 13, 2017
rikyrah
This is it: There will be a big PEOPLE’S FILIBUSTER at the U.S. Capitol next Mon. and Tues. => https://t.co/JQ57BUxU0A
Please RT
— Topher Spiro (@TopherSpiro) July 14, 2017
rikyrah
New version of #Trumpcare exempts Congress.
So worse care for everyone except the people who vote for the bill! https://t.co/g7fVZ481hy
— Chris Murphy (@ChrisMurphyCT) July 13, 2017
rikyrah
NEW: Cheat sheet on Senate health bill. Is GOP keeping their promise to repeal the ACA?
What is repealed and what isn’t.
RT if helpful. pic.twitter.com/Z3AsMPj3Nz
— Andy Slavitt (@ASlavitt) July 14, 2017
Ruckus
@Bradley Flansbaum:
The patient experiences is on the cost side and the admin experiences is on the saving side. In an MBA spreadsheet these are completely different things, no matter that both use money to measure what they are doing. Simply, spending money in the building to save money is better than spending money outside the building on the product.
rikyrah
The Cruelty and Fraudulence of Mitch McConnell’s Health Bill, via @nytimes https://t.co/lgj1vXyMDG
— Judy Solomon (@JudyCBPP) July 14, 2017
Yarrow
Has anyone done analysis of how this horrible bill affects MediCARE users? Because they’re the ones who vote Republican. Did it screw them too?
rikyrah
In both House & Senate, GOP added late provisions cutting protections for ppl with pre-existing conditions, with little ‘moderate’ pushback.
— Taniel (@Taniel) July 14, 2017
rikyrah
Drs/RNs send 20-45 sec videos to @HouseCallsAHCA and we will post. Remind @USSenate that #HealthcareBill will harm patients #protectourcare pic.twitter.com/dWBfzYEPpI
— HOUSE CALLS CAMPAIGN (@HouseCallsAHCA) July 14, 2017
rikyrah
Reporters- #TheResistance is huge. It’s not some fringe group. I’ll prove it. Retweet this if you’re a proud member of The Resistance.
— Scott Dworkin (@funder) July 14, 2017
Ruckus
@Yarrow:
And they don’t care which as long as it costs them nothing. Or better still if they can make a buck off of either.
rikyrah
This is a blistering ad: “Senators did make the bill better for one group of Americans…themselves.” https://t.co/sNbipQZDL6
— Topher Spiro (@TopherSpiro) July 14, 2017
Yarrow
@Ruckus: True enough.
@rikyrah: I used this argument with the people I got on the phone. “Why are the making things better for themselves and worse for everyone else? How do you feel getting screwed by your boss?”
TenguPhule
@rikyrah:
Of course it does.
I believe the number of people who think this all isn’t going to end in Civil War is dropping.
The Republican are doing everything short of rounding up people for concentration camps.
And the year isn’t over yet.
d58826
Well one small (very small) island of common sense
http://www.huffingtonpost.com/entry/protester-laughed-jeff-sessions-sentenced_us_5967de92e4b0d6341fe7a9e2?4r
d58826
Pence running his mouth. Now I’m not an expert on all of this but why do the health care needs of people vary from state tot state? Do women give birth differently in TX than in PA? Is the appendix in a different part of the body in CA vs WI? Now I can see that maybe frostbite isn’t a big issue in FLA or malaria in MN but most of the rest of what ails us seems kind of generic.
Now if you re-phrase that to say
then that makes sensed.
Another Scott
@rikyrah: LOLGOP has been on fire about these horrible Senate bills.
Cheers,
Scott.
Greg in PDX
I have Medicaid (Oregon Health PLan) and I think is superior to any private insurance. Every doctor here accepts it. I have a GP and a GI through OHSU, which is the most prestigious hospital here. I have had ultrasounds, MRIs, phlebotomies, you name it, and I am treated exactly as if I had private insurance. They have just added dental as well. I have no trouble getting an appointment. The last time I needed to schedule a visit they were able to see me in three days. The care has been all around above average. And the best part? No premiums, no co-pays, no deductibles. Zero. Zilch. Any prescription I need is free. I am on disability, so I was assigned to Oregon Health Plan by default. Enrollment took about 15 minutes on line, and my coverage started the next day. On the other hand, when I lived in Texas for 3 horrible years, they would have let me die in the street before giving me access to a decent doctor. I won’t go into details, but I am uninsurable in the private market, I went without insurance for six years and ended up nearly dying because of it. I suspect that people who say that Medicaid is horrible live in shithole red states (like Texas!) where their government begrudges any dime they have to pay for common decency to other human beings.
Ruckus
@Greg in PDX:
Common decency is like common sense. It might actually be common if more people had some.