Opinion Column

Medicaid’s Moment (Guest Opinion)

If there is a piñata in American health care politics, it is Medicaid, the essential coverage program for more than 52 million low-income and vulnerable Americans, with 16 million more scheduled to enroll beginning in 2014.

In recent years, Medicaid has been the target of unrelenting attacks from Republicans and conservative think tanks. During the Senate debate on the Affordable Care Act, Sen. Robert Corker, R-Tenn., called Medicaid “probably the worst health care program in America.” Sen. Richard Burr, R-N.C., said it was “the most dysfunctional delivery system that exists in the American health care system.” Sen. John Cornyn, R-Texas, labeled it a “health care gulag.” And, back in March, American Enterprise Institute Fellow Scott Gottlieb, a physician, penned a Wall Street Journal op-ed entitled “Medicaid Is Worse Than No Coverage At All.”

Disappointingly, while Democrats are effusive in their praise of Medicare, their silence in response to public attacks on Medicaid has been deafening — during the fight over health reform legislation and since.

All the more important, then, is the study released this month by the National Bureau of Economic Research, “The Oregon Health Insurance Experiment: Evidence From The First Year,” written by a distinguished panel of health care economists.

I remember learning in 2008 that the state of Oregon had decided to hold a lottery to determine which uninsured Oregonians would be permitted to enroll in a limited expansion of their state’s Medicaid program. A total of 89,824 persons applied for 10,000 slots.

Although at the time I rolled my eyes at the sad and ludicrous spectacle of a lottery for health security, my colleague at the Harvard School of Public Health, Kate Baicker, and MIT economist Amy Finkelstein, had a different reaction. They saw this as a fleeting and historic opportunity to conduct the gold-standard of empirical research, a randomized controlled trial, to evaluate the benefits of Medicaid coverage versus no coverage at all.

In the U.S. (Europeans, of course, have no reason to study uninsurance), only one significant randomized controlled trial has been done — ever — to study health insurance. It was the 1970s RAND health insurance study, which examined consumer behavior under varied insurance designs (the lead investigator in that effort, Harvard’s Joseph Newhouse, also was involved in the Oregon study). Lack of health insurance was not part of the RAND study design. Now, the Oregon health insurance experiment will join RAND in the pantheon of essential health services research.

There will be many more results, reports and studies to come, but the first report already includes vital findings. The lucky Oregonians newly enrolled in Medicaid experienced:

? A 30 percent increase in the probability of a hospital admission.
? A 15 percent increase in the probability of taking a prescription drug.
? A 35 percent increase in the probability of having an outpatient visit.
? A 25 percent decline in the probability of having an unpaid medical bill sent to a collection agency.
? A 35 percent decline in having any out-of-pocket medical expenditures.
? Across-the-board improvements in self-reported physical and mental health, including “a general sense of improved well-being.”

The study population — new Medicaid enrollees and their unlucky uninsured counterparts — was not healthy: 18 percent had diabetes compared with 7 percent of the general population; 28 percent had asthma compared with 14 percent of the general population; 56 percent had been screened for depression versus 28 percent of the general population. Happily, researchers found a significant increase among the new enrollees in seeking basic recommended preventive care tests. For instance, data showed a 20 percent increase in cholesterol screening, a 15 percent increase in diabetes testing, a 60 percent jump in mammograms and a 45 percent hike in pap tests.

All four measures of financial strain — out-of-pocket medical costs, medical debts, refusal of treatment because of the cost of care or skipping payment of other bills to pay medical expenses — showed significant declines for these new enrollees. No wonder, then, that researchers found “an overwhelming sense from the survey outcomes that individuals feel better about their health and … their interactions with the health care system. … The evidence suggests that people feel better off due to insurance.”

Naysayers are already out in force charging that the study results fail to identify actual improvements in enrollees’ health status. Those kinds of results are down the road. Though in this case, their beef is not with Medicaid or the Oregon study, it is with health insurance generally. Critics should try to convince non-poor Americans these services are unnecessary and unhelpful before foisting this straw-man on the poor.

The authors are careful not to predict from their research the likely outcomes of the 2014 Medicaid expansion built into the health reform law. They did not need to. From now on, those who allege that Medicaid is “worse than no coverage at all,” or who refer to it as a “health care gulag,” face a higher burden of proof. No one denies that Medicaid is full of flaws and deficiencies, and needs improvement — but its greatest detractors never propose improvements, only abandonment.

This new study is the second piece of solidly good news this year for Medicaid’s legions of supporters. According to the May 2011 Kaiser Health Tracking Poll, Americans oppose Republican proposals to block grant Medicaid to the states by a 60 to 35 percent margin — even 39 percent of Republicans oppose the idea. Americans increasingly recognize the importance of Medicaid, not just for the poor, for everyone.

All the more perplexing, then, is the near total silence of the Obama administration and congressional Democrats in talking publicly in support of America’s most vital health care safety net. And all the more discouraging are the reports of Medicaid on the chopping block for deficit-related cuts.

We can improve Medicaid and we should be bold in defending it. Thanks to the Oregon Health Study Group for making the job easier.

John E. McDonough is a professor at the Harvard School of Public Health (jmcdonough@hsph.harvard.edu).