In the eye of the be­holder

Med­i­caid study fu­els both sides in re­form de­bate

Modern Healthcare - - THE WEEK IN HEALTHCARE - Me­lanie Evans

New re­search on Med­i­caid in Ore­gon gave fresh am­mu­ni­tion to both sides of the fight over the Obama ad­min­is­tra­tion’s push to per­suade states to ex­tend Med­i­caid cov­er­age to more res­i­dents.

The study, pub­lished in the New Eng­land Jour­nal of Medicine, found that Ore­gon res­i­dents who gained Med­i­caid cov­er­age dur­ing a 2008 lot­tery vis­ited doc­tors’ of­fices more of­ten and had more pre­scrip­tions com­pared with those who didn’t get cov­ered. The lot­tery pro­vided an un­usual ran­dom­ized trial to study the de­gree to which Med­i­caid helps lower-in­come Amer­i­cans.

The re­search found no greater de­tec­tion of hy­per­ten­sion and high choles­terol among the group that gained cov­er­age. Med­i­ca­tion used to treat both con­di­tions was also sim­i­lar be­tween lot­tery win­ners and losers. And one key di­a­betes mea­sure—aver­age gly­cated he­mo­glo­bin lev­els—looked sim­i­lar be­tween the two groups, though di­ag­no­sis and pre­scrip­tions to treat di­a­betes in­creased with the safety-net in­sur­ance.

The study also showed, how­ever, that the rate of de­pres­sion de­creased among those with Med­i­caid cov­er­age and that the

in­sur­ance pro­vided fi­nan­cial pro­tec­tion from med­i­cal bills.

“Health in­sur­ance is a fi­nan­cial prod­uct that is aimed at pro­vid­ing fi­nan­cial se­cu­rity by pro­tect­ing peo­ple from cat­a­strophic health­care ex­penses if they be­come sick (and en­sur­ing that the providers who see them are paid),” the study’s au­thors wrote. “In our study, Med­i­caid cov­er­age al­most com­pletely elim­i­nated cat­a­strophic out-of-pocket med­i­cal ex­pen­di­tures.”

But the re­sults come amid a mas­sive push to ex­pand Med­i­caid cov­er­age start­ing in 2014 un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act. The ex­pan­sion, though it re­mains in ques­tion in about half the states, could add about 7 mil­lion to the pro­gram next year.

Re­sponse to the re­search has proven “a case study in con­fir­ma­tory bias,” with com­men­ta­tors tak­ing from the study what­ever will re­in­force their ex­ist­ing be­liefs about the Af­ford­able Care Act, said Ray­mond Fis­man, a fi­nance and economics pro­fes­sor at Columbia Univer­sity.

Fis­man said the study sug­gests that in­sur­ance cov­er­age and greater ac­cess to care may not be enough to man­age de­bil­i­tat­ing, costly chronic dis­ease. Bet­ter re­sults will likely re­quire more ag­gres­sive com­mu­nity out­reach, dis­ease man­age­ment and co­or­di­na­tion of care by hos­pi­tals and doc­tors. “You need a lot of com­ple­men­tary in­puts to make peo­ple health­ier,” Fis­man said.

Dr. Ashish Jha, a pro­fes­sor of health pol­icy and man­age­ment at Har­vard Univer­sity, sim­i­larly said Ore­gon’s ex­pe­ri­ence shows that cov­er­age may do lit­tle to im­prove mea­sures with­out a push to im­prove health­care qual­ity. Greater ac­cess to med­i­cal care is “nec­es­sary but not suf­fi­cient” to im­prove care, he said. “If you want to im­prove out­comes, it has to be good health­care.”

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