In the eye of the beholder
Medicaid study fuels both sides in reform debate
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.”