A new study published in JAMA Surgery calls into question the potential impact of a central piece of the Patient Protection and Affordable Care Act: the Medicaid expansion.
The law extends Medicaid to people up to 138 percent of the federal poverty level (FPL). For states that proceed with the expansion, the federal government will support 100 percent of the expansion costs from 2014 through 2016. After which, the federal match will gradually decrease to 90 percent by 2020.
The president and his supporters have pitched the Medicaid expansion as a way to bring more people into the system and improve the medical care of the uninsured and underinsured.
The study, which followed non-elderly adults who had inpatient surgery at 52 hospitals in the state of Michigan between July 2012 and June 2013, challenges these assertions. The research provides a window into the medical care awaiting the millions of newly eligible Medicaid patients, and it isn’t pretty.
The researchers looked at surgical outcomes based on insurance status. Despite the fact that the Medicaid patients in the study were on average younger, the Medicaid patients had a greater percentage of postoperative complications, major complications, and higher mortality after the procedure compared to the patients with private insurance. These results were all statistically significant with a p value <.01. Medicaid patients were over twice as likely to die after the surgery than patients with private insurance.
In the study, the researchers also found that patients on Medicaid had greater lengths of hospital stay compared to patients with private insurance and were more likely to be readmitted. So much for the ACA bending the cost curve.
This research raises serious concerns about the care that Medicaid patients receive. While the results are striking, they are by no means novel. A panoply of other research exploring other medical and surgical interventions published in a wide-range of peer-reviewed journals has reached similar conclusions.
1993 research in the New England Journal of Medicine studied 4,675 women who were diagnosed with breast cancer from 1985 to 1987. The authors discovered that patients without insurance and on Medicaid were diagnosed with breast cancer at more advanced stages than patients with private insurance. Even after the researchers corrected for potential confounders, Medicaid patients had an adjusted risk of death 40 percent higher than patients with private insurance at 54 to 89 months after the initial diagnosis.
Medicaid is a deeply-flawed program. Its rigid statute leaves state policy makers with few options to control rising costs other than paying providers less and less. As a result, Medicaid provider reimbursements are significantly below those of Medicare and private reimbursements. For example, according to the Kaiser Family Foundation, in 2008 Medicaid payments nationally for all services were on average 72 percent of Medicare rates. As a result of these uncompetitive rates, many physicians are reluctant to accept Medicaid patients, especially new ones. Health Affairs research has found that only 69 percent of physicians are accepting new Medicaid patients.
The brunt of Medicaid’s flaws are passed along to its beneficiaries in the form of restricted access, long wait times for appointments, and as the new study suggests: compromised care.
Unfortunately, the Medicaid expansion is no magic pill for Medicaid’s ailments; it will merely bring these problems to more people and likely exacerbate them by putting even more strain on the system.
Rather than expanding the Medicaid rolls, states need more flexibility to innovate and make the program work for the state and the underserved.