Regardless of what happens to the Affordable Care Act (ACA) — whether it rolls out as planned over the next several years or is repealed under a new Republican administration — American health care still will face perhaps its biggest challenge: caring for the sickest and the poorest. Analysts from across the ideological spectrum agree on the urgency of the challenge, but solutions remain elusive.
Today, Medicaid, which is funded jointly by states and the federal government, provides care for poor families with children as well as many people with severe disabilities; it also provides long-term-care, mostly in nursing homes, for the low-income elderly. But as the costs of care have risen far faster than incomes, more Americans who fall outside these coverage categories continue to lose access to care. In 2010, 49.1 million Americans were uninsured. (As of June 2011, 52.6 million people were covered by Medicaid.)
“You can be penniless” and yet receive no assistance in getting health coverage, says Ron Pollack, founding executive director of the national consumer-advocacy group Families USA. “We have 42 states that don't do anything for adults without children,” making the Medicaid safety net “more holes than webbing,” he says. But the ACA aims to remedy the problem by expanding Medicaid to low-income childless adults.
Some liberals have long predicted that such an expansion would not only provide much-needed access to care but also save money. The savings would come from poor people getting preventive health care rather than ending up seeking expensive emergency room treatment after long-untreated medical conditions worsened. Some conservative commentators, on the other hand, scoff at the ACA expansion, arguing that Medicaid is such a skimpy program and pays doctors and hospitals so little that the new Medicaid enrollees will gain almost nothing of value.
“There's a lot of rhetoric on both sides” of the Medicaid-expansion question, says Katherine Baicker, a professor of health policy at the Harvard School of Public Health. She says new data she and other scholars collected show clearly that the most extreme claims of both proponents and detractors miss the mark.
The scholars, who also include Amy Finkelstein, a Massachusetts Institute of Technology economics professor, conducted the first-ever research on insurance coverage using the most rigorous standards of scientific evidence, says Baicker. In the study, nearly 90,000 very low-income Oregonians, ages 19 to 64, signed up for a lottery that randomly assigned them either to the Oregon Health Plan or left them uninsured. The research, which is ongoing, ultimately will examine and compare the health care usage, health status and financial situations of both the group covered under the state health plan and those in the uninsured control group.
The data show that, after one year, those who gained Medicaid coverage gave their health status better marks than did their uninsured peers, and they also faced far fewer struggles with medical bills, says Baicker. The newly insured were more likely to describe their health as good and improving and themselves as happier than did the uninsured, she says.
In addition, the newly insured were 25 percent less likely to have had an unpaid medical bill sent to a collection agency and 40 percent less likely to have had to borrow money or leave other bills unpaid to pay their medical bills.
These findings prove that “expanding Medicaid has real benefits,” not just for health but for people's financial status as well, says Baicker. The findings should effectively end speculation by Medicaid's critics that the program would be of no help to people if it were expanded, she says.
The data don't “tell you whether it's a good idea to expand Medicaid, but they do give you information about what the effects are,” on individuals and on government budgets, Baicker says.
Nevertheless, the same data also dampens expectations by Medicaid-expansion supporters that hospital use might decline, along with expenses, if more people receive Medicaid coverage, says Baicker. Instead, she says, “we found a substantial increase [in hospital use], at least in the first year,” she says. Still, she says, the increase came in scheduled hospital care such as non-emergency surgeries, not in pricey emergency-room visits that sometimes result from neglected preventive care.
Meanwhile, conservative economists who hope to see the ACA repealed and replaced with a less-regulated, more market-oriented system also acknowledge the importance — and trickiness — of serving the poorest and sickest people while allowing a free market to flourish in health care for the rest of the population.
“Sometimes there's a tendency to think only in dollar terms, but that's not the be-all and end-all,” says Thomas Miller, a resident fellow at the free-market-oriented American Enterprise Institute. Miller says “you need a health care system that works for people” — both the poorest and sickest, who need more assistance than others, and the rest of the population, who are best served by having a health care market that offers them choices.
“You need first to acknowledge that the very poor or the very sick must get more” help to meet costs, Miller says. But at the same time, he adds, “you want to allow a wider variety of choices” for others so that savvy consumers can drive the market toward better quality and lower cost. Subsidies are required for the poor under any system, but the ACA's subsidies are too rich and reach people who earn too much, thereby undercutting the incentives for wiser spending, he says.
— Marcia Clemmitt