Category: Medicaid

Medicaid Patients Use the ER Because They Have To, Not Because They Want To

It is well established that Medicaid patients use emergency rooms more than either uninsured or privately insured patients. What has been debated is whether their use of the ER is necessary or unnecessary. Well, it turns out that that depends on how you look at it. Obviously, not many people go to the ER because they enjoy the experience and have nothing better to do. However, medical problems that cause them to go to the ER could often be dealt with in a doctor’s office.

The Medicaid and CHIP Payment and Access Commission (MACPac) has just published a review of articles examining why Medicaid patients frequent the ER so much:

The majority of ED visits by non-elderly Medicaid patients are for urgent symptoms and serious medical problems that require prompt medical attention…

7.2 Million More Americans Dependent on Medicaid since Obamacare Opened

The Center for Medicare & Medicaid Services (CMS) has just released more data corroborating our previous conclusion that Obamacare is mostly an expansion of welfare dependency:

The 48 states reporting both June 2014 enrollment data and data from July-September 2013 report total enrollment in June of over 65 million individuals, and July-September 2013 average enrollment of 58 million. For June 2014, we are reporting growth of 7.2 million compared to July-September 2013…

What is really remarkable is that the government thinks this is something to be proud of. It is a far greater number than the increase in those enrolled in individual plans (even with Obamacare subsidies), and will impose a significant drag on employment growth as long as Obamacare’s Medicaid expansion persists.

Medicaid’s Perverse Financing Merry-Go-Round

health-insuranceMedicaid, which provides health-related welfare benefits to low-income individuals, is jointly financed by the federal and state governments. Before Obamacare, the split was 50/50 for rich states, but low-income states got more dollars. This mechanism is called the Federal Medicaid Assistance Percentage (FMAP). So, if California spent $50 on Medicaid, the federal taxpayer would chip in $50. However, for West Virginia, the split is 28.65/71.35. That is, for every hundred dollars spent on Medicaid, only $28.65 is spent by the state, and $71.35 comes from federal taxpayers. These dollars are not appropriated by Congress: They just roll out on auto-pilot, as calculated by the FMAP.

Obamacare Enrollment is Mostly Medicaid Expansion

The Urban Institute produces a quarterly survey of Obamacare enrollment. The latest corroborates that Obamacare enrollment is largely an increase in Medicaid dependency. Let me start off by repeating the same criticism I have made of the Gallup-Healthways survey. Namely, that this survey does not differentiate between people who were uninsured for one month before signing up for Obamacare and those who were uninsured for twelve months. This leads to a too high baseline measurement of the uninsured.

Nevertheless, there is a reduction in the proportion of uninsured, and it is much larger in states that expanded Medicaid than in states that did not [Figure 1]:

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Is Medicaid Crowd-Out the Only Effect of Obamacare?

Medicaid “crowd-out” is the hypothesis that enrolling more people in Medicaid will cause some people to drop private coverage in favor of Medicaid. Historical analyses of this effect come to a wide range of estimates, as Linda Gorman discussed in a recent blog entry.

Now courtesy of the Robert Wood Johnson Foundation (RWJF), we have evidence that the entire effect of Obamacare so far is to crowd out private coverage. The RWJF report further confuses the consequences of Obamacare on coverage and access to care. This is not the RWJF’s fault: The emerging evidence on Obamacare is a jumble of contradictions. In this instance, the report insists that physicians saw no increase in patient demand after Obamacare, as demonstrated in Figure 2. More sophisticated metrics showed that the complexity of patients’ needs also did not increase after Obamacare.

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The Mystery of Hospitals’ Medicaid Profitability: Evidence from Arizona

Advocates of consumer-driven health reform want to shrink the role of government. One of the things we want is for Medicaid dependents to have greater choice of coverage, perhaps even through vouchers or tax credits that would allow them to choose private coverage. We know that Medicaid patients face poor access to care and that increasing the number of people on Medicaid increases emergency-department use. And yet, it has also been argued that hospitals lose money on Medicaid patients. However, this cannot make sense because hospitals constantly lobby to expand Medicaid. They never join with proposals to move Medicaid patients to private coverage. This is especially baffling because scholars also believe that some proportion of people who take advantage of a Medicaid expansion drop private coverage to take up Medicaid.

Evidence from Arizona leads to an explanation. Arizona hospitals heavily lobbied Governor Brewer to expand Medicaid in line with Obamacare. This expansion resulted in a reduction in so-called “uncompensated costs” from about 8 percent of hospitals’ revenue in the summer of 2013 to under 5 percent in April 2014. As well, Arizona hospitals operating margin increased from $140 million for 2013 to date to $184 million for 2014 to date, an increase in operation margin from 4.0 percent to 5.2 percent.

Puzzle of the Day: Medicaid Expansion and Unavoidable Emergency Department Visits

Ambulance at Emergency EntranceTo paraphrase John Wayne, evaluating health care is hard. It is even harder if you use percentages.

A 2011 report on whether or not Wisconsin’s BadgerCare’s coverage of childless adults affected their utilization of services concluded that people in a sample of about 10,000 very low income childless Milwaukee adults increased their total emergency department visits by 39 percent when they were newly enrolled in Medicaid coverage.

Seventeen percent of visits resulted in a hospital admission before Medicaid was expanded to cover the group. After expansion, 9.5 percent of emergency department visits resulted in a hospital admission.

The report spins this like it was a good outcome: “This significant 45% decline is notable in that Wisconsin Medicaid payment policy considers an ED visit ‘appropriate’ when it results in a hospital admission.” Later on, the report reminded readers that “the percentage of hospital admissions from the emergency department declined dramatically.”

Medicaid Spending More Than Doubled, 1999-2010

Sometimes a picture tells a thousand words. And this growth in Medicaid dependency happened mostly during a Republican Administration, well before ObamaCare’s expansion. And the trend from 2006 through 2010 is straight. That is, the 2008 financial crisis and subsequent recession did not cause the expansion. It’s just what our government does, apparently.

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Yet More Reasons Why Doctors Do Not Participate in Medicaid

Claims about Medicaid’s effectiveness should be approached with caution simply because the population covered by Medicaid differs from that covered by private insurance in ways a variety of ways that are likely to affect overall health.

For example, Medicaid patients are more likely to be no-shows for medical appointments. No-shows are typically defined as either not showing up at all or calling to cancel on the same day. In one orthodontic practice, Medicaid patients accounted for almost 40 percent of missed appointments but only 27 percent of all appointments. Children most likely to miss dental visits were those with lots of cavities, poor behavior, multiple missed appointments, and no phone.

Broken appointments translate into a reimbursement rate of zero. Surveys of dentists suggest that they are even more important than low reimbursements in dentists’ refusal to participate in Medicaid.

The pattern does not change for more involved procedures like cochlear implants. At Children’s Hospital in Cleveland, Ohio, access to cochlear implants is the same whether patients are covered by Medicaid or by private insurance. But medical complications do vary with a patient’s insurance status. From 1996 to 2008, 133 children received unilateral cochlear implants. Complications in Medicaid-insured children were 5 times those in privately insured patients with 10 complications in 51 Medicaid-insured patients and 3 complications in 61 privately insured patients. Medicaid patients missed 35 percent of follow-up appointments. Privately insured patients missed 23 percent of follow-up appointments.

Given that behavioral differences exist for something as simple as keeping an appointment, challenges to getting high-quality care to Medicaid patients cannot be solved by just expanding Medicaid budgets.

Three Million People Who Applied for Medicaid During the ObamaCare Surge are Still Waiting to be Enrolled

health-insuranceThe survey’s estimate of at least 2.9 million unprocessed applications is a conservative tally because some states didn’t furnish all of the requested information.

Thirty-six states rely on the federal insurance site healthcare.gov to transmit applications of people federal officials believe will qualify for Medicaid. Six of those states provided CQ Roll Call with the number of applications still stuck at the federal marketplace but couldn’t say how many people were covered. Eleven offered numbers for pending applications that had been transferred but similarly didn’t know the number of individuals covered in the paperwork.

It’s also important to note that the 2.9 million estimate is for the number of people waiting for their initial application to be processed. Some recipients waiting for a decision reapplied directly to the states and were approved. Officials in many states will have to spend additional sums to weed out duplicate applications and eliminate the risk of double-counting. (Roll Call)