FOR IMMEDIATE RELEASE: October 17, 2019
Contact: Adam Gaffney, Instructor in Medicine, Harvard Medical School; President, Physicians for a National Health Program; Division of Pulmonary and Critical Care Medicine, Cambridge Health Alliance; agaffney@cha.harvard.edu; Clare Fauke, Communications Specialist, Physicians for a National Health Program, clare@pnhp.org, 312-782-6006
The cost of a Medicare for All program has been hotly debated. Analysts at the Urban Institute have projected that universal coverage would cause the use of health care services — and consequently the nation’s health care spending bill — to soar. However, new research from Harvard Medical School suggests that such predictions are probably wrong. The study, appearing today in the American Journal of Public Health, examines the implementation of large-scale coverage expansions under Medicare and Medicaid in the 1960s and the Affordable Care Act (ACA) in 2014. Researchers found that in both cases, the use of physician services rose among lower-income individuals, but those increases were fully offset by small decreases among the well-off. As a result, the overall use of physician care did not change.
The researchers’ findings suggest that universal health coverage would not cause doctor visits to soar, and that Medicare for All would be less costly than many analysts have predicted.
The researchers found that before the implementation of Medicare and Medicaid in 1966, Americans averaged 427 doctor visits, and 7 surgical procedures, per 100 persons annually. After these programs were implemented, these figures were virtually unchanged at 425 and 7 per 100 persons, respectively. Similarly, the rates of doctor visits and surgical procedure did not change at all after the ACA’s implementation in 2014, remaining at 372 visits and 16 procedures per 100 persons.
The data shows that low-income persons had increases in doctor visits and surgical procedures after both the Medicare and ACA coverage expansions; use also rose among the elderly after Medicare. However, very small reductions in utilization among higher-income individuals counterbalanced these increases. These findings suggest that coverage expansions allowed physicians to direct care to patients who need it most, rather than to those best able to pay.
A previous study by the same researchers examined the effect of these two coverage expansions on hospital use, which currently accounts for about a third of health care spending, and similarly found no rise in hospitalizations in the wake of their implementation. The new study extends these findings to physician services, which currently account for about a fifth of health care spending
“Physicians tend to keep their schedules full,” noted study author Dr. Danny McCormick, a primary care doctor and associate professor at Harvard Medical School. “It isn’t surprising that increased use among newly covered would be offset by very small reductions in potentially superfluous services provided to well-off individuals,” he added.
Surprisingly, despite the small decreases in their doctor visit rates, well-off individuals perceived little change in their ability to get care after the ACA’s implementation. Although survey data for the Medicare era is lacking, the authors state that news reports from 1966 indicate that predictions of care shortages never materialized.
“After both coverage expansions, people who had previously been insured could still see doctors when they wanted or needed to,” commented study author Dr. Steffie Woolhandler, a lecturer at Harvard Medical School and distinguished professor at the City University of New York. “Physicians probably reduced the amount of unnecessary and low-priority care they’d been providing to the well-off. We know from studies in Canada that this is also what happened when they implemented a single-payer program.”
“Our findings suggest that a Medicare for All reform would be more affordable than commonly thought,” noted lead author Dr. Adam Gaffney, an instructor at Harvard Medical School and a pulmonary and critical care specialist. “Coverage expansions allow physicians to direct their time and services to those who need it, not merely those who are well-off. These experiences from our history show that Medicare for All probably won’t cause overall society-wide health care use — and consequently costs — to soar.”
“Coverage Expansions and Utilization of Physician Care: Evidence From the 2014 Affordable Care Act and 1966 Medicare/Medicaid Expansions.” Adam Gaffney, MD, MPH; Danny McCormick, MD; David Bor, MD; Steffie Woolhandler, MD, MPH; David Himmelstein, MD. American Journal of Public Health, published online Oct. 17, 2019. DOI: 10.2105/AJPH.2019.305330
Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.
