Not News, But History - A New Look at Medicaid Expansion

                لمشاهدة الفيديو كامل HD 
              والتحميل مجانا

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Now that 2014 and Obamacare are both here, there will be plenty of stories about Affordable Care Act implementation.  Some will be newsworthy; but others will just be history. 

Last week, we got our first history story characterized as exploding news.

The Washington Post reported on a newly-released Harvard study that analyzed the impact of the 2008 Oregon Medicaid expansion on hospital emergency department visits.  The study found that there was a 40 percent increase in the number of emergency department visits made by the new Medicaid enrollees.

For the Post article, an MIT health economist (I guess no Harvard ones were available!) commented  that he viewed it “as part of a broader set of evidence that covering people with health insurance doesn’t save money,” something he went on to characterize as a “misleading motivator for the Affordable Care Act.”

And Forbes went farther, claiming the study results are “undermining [the] central rationale” for ACA.

But the Oregon expansion increase wasn’t really news by itself, and it tells us nothing about the Affordable Care Act, either.

There are three reasons for this.

The first reason is that Medicaid recipients, as a group, have always been the most frequent users of emergency department care. 

I learned about this up close when I was involved in a community health project in Austin, TX, more than a decade ago. 

We compared the use of emergency departments for non-emergent reasons by privately insured, Medicaid-insured, and uninsured residents.  About half the visits made by privately insured or uninsured people were for non-emergent reasons.  But 60 percent of those made by Medicaid recipients were for non-emergencies. 

The same thing was true when that analysis was repeated in other hospitals in other parts of the country.

So the new study simply confirms what we have known to be the case for years.  Medicaid recipients use hospital emergency departments for non-emergent care more frequently than those who are not on Medicaid.

The second reason is that we also know why Medicaid recipients have historically gone to emergency departments for their non-emergency care. 

It isn’t that emergency rooms are more conveniently located than private doctors and walk-in clinics.  Or that some hospitals now use billboards, texting, or other mass media to advertise shorter emergency department waiting times.

It is simply because – unlike many private primary care providers – hospitals have historically been paid enough to take part in the Medicaid system. 

But there are new realities under the Affordable Care Act.  More federally-qualified health centers are being approved, and other private primary care providers are seeing increased rates – rates comparable to Medicare – for treating Medicaid patients.

While change won’t happen overnight, this means that over time more private providers will be signing up for Medicaid in the expanded Medicaid program, and more Medicaid patients will be choosing them over hospital emergency departments because they can.

And that makes the results of an expansion program that took place six years ago an interesting history lesson, but as poor a predictor of what will happen in the future under a different set of rules as historical stock market performance is of future returns.

The third reason is that cost-savings was not a “misleading motivator” for supporting the Affordable Care Act.

Despite the suggestion of the MIT economist and the Forbes headliner, it wasn’t actually a reason at all.  When the Act was debated in 2009 and 2010, it was clear to all that it was essentially cost-neutral. 

Both the CBO and the Administration projected that we were going to be spending about the same amount on health care overall for the next ten years whether or not we passed the law.  But the law would distribute the costs and savings differently.

Medicare and Medicaid would take on a slightly greater share of costs.  Out-of-pocket costs not covered by public or private insurance would go down (especially for those with chronic diseases and conditions who could not afford insurance in the past).  And private insurance would continue to pay just about one-third of the nation’s health care bill.

While not everyone in the media may have known this at the time, all the people voting on the law did.

That’s not news.  That’s history.

Just like the new Harvard study.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Obamacare Crashes Again?

There are bad reviews and then there are bad reviews.  But it would be difficult to imagine some worse headlines than the ones Obamacare has received during the past month.

My favorite for over-the-top headline?  How about this gem from the National Journal: “Why Obamacare May Be Obama’s Katrina, Iraq.” That’s right.  An initiative to insure millions of Americans has been equated with the most frightening American natural and man-made disasters of the 21^st century. 

In a world in which we have come to expect tight plotlines, heroic successes, and quick and satisfying endings, I imagine that a blockbuster like Obamacare was never going appeal to critics.

The Obamacare story is being reported this month as if it were a classic disaster movie, with millions of people about to be left out in the cold to fend for themselves in a chaotic healthcare system as Obamacare exchanges crash and burn around them.

But that’s not close to reality.

This week’s announcement that the Obamacare website will work 90 percent of the time (which is another way of saying it still could be down over two hours per day) is hardly worth celebrating.  But the truth is that Obamacare itself is unfolding pretty much as expected.  The changes to the system that have been in place are for the most part popular and glitch-free.

And in another thirty days, people with pre-existing conditions will be guaranteed insurance at the same price as everyone else.  In roughly half the country, people with incomes below 138 percent of poverty will start to receive Medicaid benefits.  And nearly everyone with incomes up to 400 percent of poverty who purchase insurance through the exchanges will be given tax credits that make it more affordable.

But one big number – seven million – is already setting up Obamacare for a disaster sequel in the spring.

That’s the number of people who are supposed to get insurance through Obamacare exchanges by March.  And when the October and November numbers were slower than desired, another Obamacare disaster narrative began to take shape.

But no one ever thought that signing up seven million people would be effortless.

In fact, way back in March, Phil Galewicz wrote an insightful and prescient article for Kaiser Health News in collaboration with the Washington Post.  He quoted several people who are familiar with the challenges of enrolling people in health insurance programs.  He and they highlighted some of the issues that would confront the Obamacare exchanges.  The article’s conclusion?  People should be prepared for a “slow ramp up.”

In this context, some of the early numbers don’t look so bad after all.

Californians alone had completed over 360,000 insurance applications as of November 19.  Covered California - the state’s exchange – reported that 135,000 would qualify for the state Medicaid program and 80,000 others had already selected a health plan. 

And, according to the exchange, sufficient numbers of those people appeared to be young enough that the California program wouldn’t sink into the sea.

In New York, the reality was similar. As of November 24, according to its marketplace, NY State of Health, over 257,000 people had completed applications, and over 57,000 people were enrolled in insurance plans.

And in Kentucky, 60,000 people have already obtained either Medicaid or private insurance through its exchange.  And of those signing up for private insurance, 41 percent are in the 18-34 year old group.

CNN also reported in mid-November that the Washington and Connecticut exchanges were generating healthy enrollment numbers.  And the federal exchange numbers were not as bad as one might expect.  The November numbers included over 100,000 sign-ups despite the balky website, and according to HHS and CNN over 900,000 more people had completed applications. 

So how did CNN headine this good news?  “Obamacare success story sours.”

What will it mean if 4 or 5 million, not seven million, people enroll by next spring?  That will be enough to drop the uninsured percentage nationally from 15.4 percent to around 14 percent.

That might warrant some favorable reviews.

But if the reporting of the Obamacare story next spring is anything like it has been over the past month, the headline you will be reading may well be “Obamacare Crashes Again.”

So stay tuned.  And in the meantime, imagine what things would be like if the alternative to Obamacare had passed.  And believe it or not, there is one – from 2009.  In my next column, I’ll take a look at how it might be faring today.  You’ll be surprised.  

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/