Bacon's Rebellion

Democracy Thrives in Sunlight

Before Expanding Medicaid, Examine the Program’s Outcomes

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by

James A. Bacon
in

When Virginia lawmakers start cranking up the old Medicaid-expansion jalopy in January, they would be well advised to pay attention to a new study out of California — not exactly your reddest of red states, so this is not Republican propaganda.

The study, published in the Journal of the American Medical Association Oncology, used a California data registry to compare cancer survival outcomes of insurance over two decades (1997–2014). Summarizes the Federalist: “Improvements in survival rates during the time period the survey examined came almost exclusively from individuals with private insurance or Medicare. “[F]or patients with other public [i.e., Medicaid] or no insurance, survival was often stubbornly unchanged, or, in some cancers, declining.”

While survival falls short of that achieved by patients with private insurance, public insurance such as Medicaid does confer a survival benefit over no insurance for breast, prostate, and lung cancer. However, there was little or no benefit of public insurance over no insurance for colorectal cancer or melanoma, and the lack of improvement in survival is a concern. These findings suggest that the health care provided to publically [sic] insured patients with cancer in California is not adequately meeting their needs.

Got that? Medicaid is somewhat better than zero insurance for some cancers but no better for others. And in some cases, the study implies, it’s worse.

Meanwhile, debates are raging over whether Medicaid expansion has led to an increase in opioid addiction, and whether or not emergency-room usage has declined, as envisioned by the architects of the Affordable Care Act.

The assumption behind Medicaid expansion is that any health coverage, no matter how crappy, is better than none at all. But Medicaid reimburses physicians far less than private insurance and Medicare do, with the result that (a) many physicians don’t take Medicaid patients, and (b) some physicians may not provide the same quality of treatment. Also, one must consider the nature of Medicaid patients. By definition, they are poor, and poor people may interact with the health care system differently than the non-poor.

The California study inevitably will be cited by Virginia opponents to Medicaid expansion. And just as inevitably, supporters will find reasons to criticize it. Here’s how it works in early 21st-century America: Pick your desired political outcome, choose the study to justify it, and then shoot holes in opposing studies. Medical science becomes politicized just like everything else in our society that is mediated by the political class — but, of course, it’s all the other side’s fault.

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14 responses to “Before Expanding Medicaid, Examine the Program’s Outcomes”

  1. LarrytheG Avatar
    LarrytheG

    Turns out that’s not a “new” finding:

    “Cancer survival disparities by health insurance status”
    2013
    ” Abstract
    Background
    Previous studies found that in the United States, uninsured and Medicaid insured patients with breast, cervical, colorectal, head and neck, lung, prostate or uterine cancer have higher mortality or lower survival than do patients with private insurance or Medicare, even after adjustment for other factors ”

    Conclusions
    Survival from cancer appears to be related to a complex set of interrelated demographic and clinical factors of which insurance status is a part. The finding that Medicaid insured cancer patients also have worse survival than privately insured cancer patients suggests that while ensuring that everyone has adequate health insurance is an important step, additional measures are needed to address cancer survival disparities. These include: building capacity in the U.S. public health and health care systems, especially in underserved communities; education about cancer prevention, detection, and treatment; preventive and chronic health care before a diagnosis of cancer; assistance to cancer patients in accessing and navigating the health care system; and workplace policies that encourage patients’ attention to their health.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699851/

    Some folks would assert that this proves that Medicaid is expensive and not effective – therefore not worthwhile.

    Others would say MedicAid has flaws that need to be fixed in order for the money spent being cost effective.

    I think Virginia is on a better path by moving to a managed care model and I think that model actually has the potential to improve health care for others who have Medicare and other insurance including Obamacare and employer-provided.

  2. TBill Avatar
    TBill

    I hate to keep quoting WTOP Ask the Gov, but Gov McAullife feels it’s very likely to pass in the new legislative session as some Repubs have always agreed with it.

  3. LarrytheG Avatar
    LarrytheG

    yeah, I think the cancer survival thing is with respect to basic MedicAid..not the expansion.

    Basic MedicAid in many states is last ditch, last resort care when there is something obviously wrong and things are going downhill..

    as opposed to routine periodic regular visits where blood tests and screens are done to detect disease in the early stages.

    People without insurance .. and those with Medicaid just don’t go to doctors unless there is something bad wrong.. Finding and getting an appointment as a MedicAid patient, especially in underserved areas is often arduous… and those in that income tier – poverty or below – often don’t have reliable transportation.

  4. UpAgnstTheWall Avatar
    UpAgnstTheWall

    Stop the presses! You mean poor people who have worse health outcomes overall than their wealthier counterparts and are thus the population served by Medicaid are more likely to have bad health outcomes???

    And that while it does provide better outcomes for breast, lung, and prostate cancer it doesn’t move the needle on two cancers that can easily go undetected and metastasize. Why, it’s almost like maybe the care these people are getting from their doctors might be sub-optimal…I think a smart blog publisher wrote something along those lines:

    “(b) some physicians may not provide the same quality of treatment.”

    This entire post is just bizzare:

    “Hey, here’s this study that shows Medicaid increases health outcomes in 3/5 of cancers, but because it works less well on the other two it means that we need to slow down on giving people without access to health insurance access to it and consider that a study on specific types of a specific disease means that it could be true for all health inputs.”

    But the projection at the end – on top of being pure modern conservatism – was almost awe inspiring:

    “Medical science becomes politicized just like everything else in our society that is mediated by the political class — but, of course, it’s all the other side’s fault.”

    From the same guy who just wrote a post that used a study about the breakdown of city governance in Charlottesville to talk about how (((George Soros))) funding a losing Democratic candidate means that a small college town is a hotbed of radical leftism that represents a physical threat even though it was American Nazi James Anthony that murdered someone with a car and but for the grace of God would have killed more.

    You obviously don’t want the Medicaid expansion to happen in Virginia, and you’re smart enough to realize using this study to attack that expansion is easy to dismiss so you want to both cite it and distance yourself from it simultaneously by saying studies are just weapons deployed for political purposes by others. Except, of course, that is A) what you yourself do, and B) if that’s the case then nothing matters, there is no point in entering into any argumentation with an affirmative stance supported by evidence and you should just close down this entire operation.

    1. James A. Bacon Avatar
      James A. Bacon

      No, it’s really not that complicated. There is abundant conclusive evidence that the Medicaid program adds little to positive medical outcomes, although that conclusion has been disputed. Before we expand the program in the expectation that it will improve outcomes, it would pay to examine the research and get clear expectations of what results we can realistically expect.

      To do so does not imply abandoning the effort to improve health care for poor people. Perhaps it will point us to a better way of managing Medicaid, or perhaps to consider alternatives that are not being considered now.

      1. LarrytheG Avatar
        LarrytheG

        yeah, right…

        we’ve had decades for those who oppose the CONCEPT of MedicAid to come up with a better way – and more often than not their “alternative” is to basically gut Medicaid because it’s “too expensive”..

        And my other favorite… kill it first then see what alternatives replace it…

        Conservatives these days are less and less able to actually deal with tough issues… their preferred alternatives are to to throw up their hands and blame people for “needing” help.

        1. James A. Bacon Avatar
          James A. Bacon

          Who’s talking about “gutting” Medicaid?

          Can you tell the difference between “gutting” Medicaid and not expanding Medicaid?

          Wow, what a world of logic you live in, Larry.

          1. LarrytheG Avatar
            LarrytheG

            “gutting” is probably hyperbole.. agree… but there is no question the continuing narrative on the right is that rising MedicAid costs are untenable and will have to be cut AND that is being used as an argument against expansion – which is a very different program that is 90% funded – not by general revenues and deficit but by separate earmarked taxes that do not affect the deficit/debt.

            so let’s state that FACT again:

            1. – regular MedicAID IS funded by general revenues both at the Federal and State level and contributes to the deficit at the Federal level and increases at the State level compete with other priorities like education.

            2. The expansion is funded from earmarked taxes not the general revenue, does not contribute to the deficit – and even though states have to put up 10%, the other 90% is covered by the Federal earmarked taxes. Analyses show that Va actually comes out ahead and the additional money offsets costs and makes it easier to balance the Virginia budget.

            My view – if the expansion was to be funded from general revenues, I would be opposed – strongly opposed.

            * – Virginia – all states – actually have the opportunity and ability to directly control costs as opposed to standing off to the side and watching other health care costs go up in the private sector market.

            * – Managed care combined with the use of centralized electronic records that any provider can access (with proper protections and permissions) – means each provider has complete access to one’s medical history and with that information – knowledge about past / current conditions, tests, therapies, etc – such that redundant and repeat efforts are reduced and treatment is better and more cost effectively delivered and duplication of efforts not reimbursed.

            * – Like transit or other things – if you reduce funding below a certain level – you affect the ability to perform and you take away the ability to develop cost-effective practices because you’re forced to pay immediately rather than invest and plan ahead to reduce costs.

            In other words, you can’t really reform and make MedicAid more cost effective and efficient if it is funded on a life-support basis.

            It will take time – and money upfront to pay for things like electronic medical records … those records will actually do things like allow folks to visit doc-in-boxes rather than ERs…

            The standard Conservative approach to not pay anymore than is absolutely necessary or even less – precludes the development of a more cost effective program longer term.

            It’s like paying VDOT only enough to fix potholes…not repave .

            It’s penny-wise and pound foolish – that’s the MO of Conservatism these days on things like MedicAid …

  5. Acbar Avatar
    Acbar

    Medicaid expansion is the right thing to do relative to the status quo. That is faint praise, and far, far, from saying Medicaid is an efficient and well-structured health services delivery system. IMHO, Medicaid is a crappy system yielding crappy results. Along with its expansion we should try to fix its incentives and inefficiencies which, after 50 years, have generated enormous tomes of analysis and criticism. But for those who have no alternative, Medicaid beats nothing, and society owes all its members better health care than nothing.

    1. TooManyTaxes Avatar
      TooManyTaxes

      Acbar – how soon do you think an expanded Medicaid program will start crowding out other state programs? And what do you think will happen then?

  6. LarrytheG Avatar
    LarrytheG

    With Conservatives , there is a certain amount of ” HEY, it’s not working so we should stop funding it” attitude … we hear that with public schools, transit, etc… as opposed to more adult real world perspective.

    Plenty of people – millions DO benefit from MedicAid. It’s not a binary success/fail calculation. Millions DO survive cancer because they DID get care BUT overall – it does not perform AS WELL as other insurance.

    that’s not a fail and a reason to de-fund and abandon – that’s a reason to reform and address the issues.

    Hells bells – if we applied that “it dont’ work” logic to VDOT and congestion – we’d shut them down as a totally wasteful and ineffective agency that has tried for decades to “defeat” congestion with little to show for their efforts!

    The fact that you wash to keep clean and you still get dirty is NOT a reason to stop washing!

    Medicaid is not nirvana and never will be but MedicAid is a vital service to people who have no other options and it actually does highlight how this country continues to have different health care for different people depending on their work and economic status – to the detriment of ALL taxpayers…

    The difference is that MedicAid is a discrete bullet in the budget but the other costs incurred in the economy as a result of a lack of adequate health care are not as easily represented

    we do have clues:

    http://www.dailyyonder.com/files/images/DisabilityMap.jpg

  7. LarrytheG Avatar
    LarrytheG

    and here:

    http://ccf.georgetown.edu/wp-content/uploads/2017/05/VA.jpg

  8. djrippert Avatar
    djrippert

    Once again, the Imperial Clown Show in Richmond is thrusting its greasy hands into your pockets.

    Adults living near or below the poverty line are approximately twice as likely to smoke cigarettes. https://www.cdc.gov/tobacco/disparities/low-ses/index.htm

    Meanwhile, Virginia has the second lowest tobacco taxes among the 50 states and the District of Columbia. Why? Because the Imperial Clown Show in Virginia wants to bestow favors on Richmond’s tobacco industry.

    Remembering that the federal support for Medicaid expansion will end, the money flow in Virginia goes something like this …

    1. Taxes are levied on people in urban areas where there is a relatively low percentage of people eligible for Medicaid. These areas also have low smoking rates.

    2. The money taken from urban areas is sluiced to rural (and some “inner city” areas) in order to provide healthcare insurance to people who can’t afford that insurance. It is wealth transfer, pure and simple.

    3. The people eligible for Medicaid (and the expanded Medicaid) are far more likely to smoke cigarettes – and incur the astonishing level of illnesses that habit brings.

    4. The General Assembly, in order to appease a very few tobacco companies clustered in the Richmond area, refuses to use taxation as a dis-incentive to smoking. This makes the cost of care for Medicaid and expanded Medicaid much more expensive.

    5. So, the real flow of money is from NoVa and Tidewater to Richmond and the rural areas of the state. The merchants of death in Richmond benefit from Virginia’s absurdly low tobacco taxes. The rural areas and some parts of Virginia’s inner cities (where personal responsibility is apparently never required) get to smoke their cheap cigarettes and have others largely pay for their stupidity when they get horrifically ill.

    Each locality in Virginia ought to be able to “opt in” or “opt out” of Medicaid expansion. The cost of opting in is agreeing to a dramatic hike in taxes on tobacco, alcohol, firearms and ammunition. The money from those increased taxes should be the first pool used to fund the Medicaid expansion.

    In the case of cigarettes I’d like to see the taxes move from 40 cents a pack to $2 a pack. And no – I don’t give a rat’s ass if that upsets the tobacco companies or the people in the Richmond area.

    1. TooManyTaxes Avatar
      TooManyTaxes

      The newly elected Democrats are holding their breath at the thought of sending more money from their constituents outstate. Meanwhile the dullards who voted for them are upset at how little NoVA gets from the State. Never overestimate the sophistication of a NoVA voter. How about limiting Medicaid expansion to people who don’t smoke? There has to be a blood test or some other type of test that can tell whether a person regularly smokes. A person who wants to quit gets money to get help to quit. If they are nonsmokers in a year, they get Medicaid.

      Absent something like this, we’ll soon see a cutback in funds for schools, public safety, etc. But that’s the goal of Democrats – ever higher taxes. And dependency.

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