Medicaid Cuts Won’t Just Hurt the Poor

Breaking Obamacare_full

The Medicaid cuts in the Senate Republican’s “new and improved” Better Care Reconciliation Act (BCRA) are not just cruel and unpopular, but they also threaten to undermine a thriving private insurance market, which is something Republicans claim to support.

In all the recent outrage over the Senate bill, no one mentioned a central fact about Medicaid: More than half of all Medicaid recipients receive their coverage through private insurance companies, who contract with state Medicaid agencies for a set fee per beneficiary. This means that the insurance companies both take on the risk and reap the rewards. And Medicaid expansion has been profitable for insurance companies. (Our ongoing research supports this finding, but we can’t provide details here while we pursue academic publication).

KFF Medicaid Map

The Medicaid/CHIP program provides health insurance for 20% of the U.S. population. In some states, more than a quarter of residents are covered by the program. In 2016 health insurers filing with the National Association of Insurance Commissioners (NAIC) reported nearly 40 million Medicaid members, representing 54% of Medicaid beneficiaries (In 2016 monthly Medicaid enrollment averaged 73.8 million).  Private insurer participation in the Medicaid market has grown significantly since the early 2000s (along with overall Medicaid enrollment). In 2001, only around a quarter of Medicaid members were covered by private health insurers.

The current Senate bill proposes not just to roll back ACA Medicaid expansion, but also to impose per capita caps on the funds states could receive. A longer term projection of the effects of the BCRA by the Congressional Budget Office (CBO) estimates Medicaid funding cuts of 35% by 2036.

WP Fed MEdicaid Spending chart
Source: Washington Post

Are Medicaid insurers making money by providing low-quality care or denying services? Medicaid opponents would have us believe the system is broken, that few doctors will accept Medicaid patients and those who do, provide inferior healthcare.

One particularly notorious claim, that Medicaid is actually worse than no insurance, is based on data from a single study. Critics have similarly latched on to the few other reports that seem to support their viewpoint, conveniently ignoring the dozens of academic papers that show positive effects of Medicaid expansion.

Recent pieces in The New York Times and the Los Angeles Times do a good job of explaining what the “negative” studies actually say and how they’ve been misrepresented. Yet the naysayers persist. See for example this article published last week.

MedicaidSatisfactionSurvey_graph

A new survey of Medicaid recipients further dilutes the negative depiction of Medicaid, with the majority of respondents indicating high levels of satisfaction with their healthcare. The National Medicaid Consumer Assessment of Healthcare Providers and System (CAHPS) survey included over 270,000 adults enrolled in Medicaid in the fall of 2013. The survey sample represented 46 states and included four categories of Medicaid recipients: 1) people with disabilities, 2) dual Medicare-Medicaid enrollees (the elderly), 3) non-disabled adults in managed care, and 4)non-disabled adults in fee-for-service medical care.

MSS Table

The managed care members (those covered by private insurers) reported satisfaction levels comparable with the total sample results. Non-disabled adults enrolled in managed care were slightly more likely to report they were able to access care and had a primary healthcare source than those in fee-for-service Medicaid.

In his defense of the Senate healthcare bill, vocal Medicaid opponent Avik Roy praised the plan for replacing Medicaid expansion “with tax credits so that low-income Americans can buy the coverage of their choice at an affordable price.” At the heart of Roy’s argument is a belief that private insurers (the market) can do a better job than government bureaucrats.

But when it comes to Medicaid, private insurers are already doing that job – not just administering funds, but taking on the risk and managing the care of millions of Medicaid recipients. They are profitable and their customers are satisfied. So why are Republicans intent on undermining the one part of the Affordable Care Act that is working for both insurers and insured?

Why is subsidizing coverage on the individual market so much more acceptable than paying for similar (or even better) coverage through Medicaid? Is a bronze-level marketplace plan with a high deductible and co-pays and limited provider networks really better than a Medicaid plan with similarly narrow networks but no out-of-pocket costs?

Proponents of single payer healthcare would like to have insurance companies removed from the U.S. healthcare system entirely. Realistically, however, any universal healthcare plan we are likely to see in the near future will involve insurance companies. Health insurers have the necessary infrastructure and the expertise to manage the unwieldy beast that is the U.S. healthcare system. And good luck getting universal healthcare through Congress (even a Democratic Congress) without insurance industry by-in. In Medicaid we already have a model for a successful public-private partnership.

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