By Andrew P. Loehrer, M.D., M.P.H.; David C. Chang, Ph.D., M.P.H., M.B.A.; John W. Scott, M.D., M.P.H.; Matthew M. Hutter, M.D., M.P.H.; Virendra I. Patel, M.D., M.P.H.; Jeffrey E. Lee, M.D.; Benjamin D. Sommers, M.D., Ph.D.
JAMA Surgery, January 24, 2018
Question: How was Medicaid expansion under the Patient Protection and Affordable Care Act associated with patient presentation with and management of common surgical conditions?
Findings: In this study of patients with 1 of 5 common surgical conditions, Medicaid expansion was associated with a 7.5–percentage point increase in insurance coverage at the time of hospital admission. The policy was also associated with patients obtaining care earlier in their disease course and with an increased probability of receiving optimal care for those conditions.
Meaning: The Patient Protection and Affordable Care Act’s Medicaid expansion was associated with increased coverage of patients, earlier presentation with common diagnoses, and improved surgical care.
From the Introduction
Uninsured and underinsured patients are significantly more likely to delay care and present with more complicated disease for conditions including appendicitis, cholecystitis, diverticulitis, aortic aneurysms, and lower extremity peripheral artery disease (PAD). Insurance status is also associated with decreased probability of receiving optimal care for such diagnoses, including a lower likelihood of minimally invasive surgery, a lower likelihood of receiving immediate cholecystectomy for acute cholecystitis, and a higher likelihood of amputation for vascular disease. The acute onset or deterioration of these diagnoses provides an ideal setting for studying short-term changes in presentation and management after population-wide insurance coverage expansion. As more individuals gain insurance coverage, one might also expect a greater probability of patients presenting earlier and with less severe disease at the time of diagnosis and in turn receiving more timely and less morbid management.
How Medicaid Fails The Poor
By Avik Roy
There are many problems with Obamacare. But the law’s cruelest feature is what it will do to low-income Americans who are already struggling. Study after study shows that patients on Medicaid do no better, and often do worse, than those with no insurance at all.
By Don McCanne, M.D.
Some conservatives have suggested that Medicaid provides such little benefit that patients might do better with no insurance at all (Avik Roy, above). This totally ignores the fact that Medicaid removes financial barriers to health care and thus improves access. The benefit of having affordable access to care is demonstrated in the study by Andrew Loehrer, et al.
The authors showed that Medicaid expansion under the Affordable Care Act resulted in more individuals being covered by the program, and that individuals with one of five major, urgent surgical conditions presented earlier in the course of their illness thus enabling management at a stage with less complexity and more favorable outcomes.
We already know that the uninsured frequently delay obtaining care and end up worse off for it. This also applies to the underinsured – people with deductibles and other cost-sharing that create a reluctance to seek care as expeditiously as they should. One of the great advantages of Medicaid is that there is usually no cost sharing and thus no hesitation because of concerns about out-of-pocket costs (though, unfortunately, several conservative governors are trying to change that now).
The lesson here is not that Medicaid is a better program – it has too many other deficiencies – but rather that requiring payment as a condition of receiving care may result in worse outcomes. A well designed single payer system has measures to contain health care spending that are much more patient-friendly than out-of-pocket cost sharing.
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