14 thoughts on “Medicaid”

  1. Most people don’t understand the way that medical “insurance” actually works. The naive interpretation is that if you get sick and go to the hospital then insurance will cover most of the cost, minus deductables and whatnot. The same way car insurance or home owners insurance works.

    In practice much of the value of “insurance” does not have anything to do with insurance at all and instead has to do with price negotiations. Having a plan with a big health company means that you pay different prices for things. And that’s where the vast majority of the “value” of the plan comes from. But as a consequence coverage is limited only to hospitals and doctors willing to be strong armed into accepting those prices, which can sometimes limit the quality of care.

    The system as a whole is very broken with many perverse incentives, but nobody has the guts to actually change it substantially. Obamacare just doubles down on an already broken system, with predictable results.

  2. Medicaid provides a set amount ofoney each month for food. The amount of food needed each month is very predictable. Medical needs can vary from month to month from anything between zero to catastrophic. So isn’t the Medicaid analogy the wrong tool for the job?

    As a physician, one of the problems that I see with making market analogies is the lack of information to caregivers and the lack of understanding on the part of patients. For example, I work in an urgent care. Someone comes in with a head injury and exhibiting some symptoms but borderline as to whether I should get the head CT. I would prefer to get the head CT for several reasons. Even if medical liability were taken out of the picture, I still don’t like bad outcomes so it would be tempting for me to recommend the head CT even if the probability of a positive was quite low.

    From the patient’s perspective, if it is completely covered by insurance then they’ll get it regardless of the cost. If the have to pay a significant co-pay or a percentage if it, then they are in a situation of considering three things:
    1) the risk to their health of not getting it,
    2) the cost of the head CT, and
    3) their near- term financial situation.

    The patient is largely dependent on that particular physician in order to assess the risk. But, even experienced physician can give widely varying estimates if what the actual calculated risk of a subdural hematoma given the specific set of signs and symptoms.

    So, I would like to see a medical decision support system freely available that would take into account specific history questions plus findings and then make that info available with calculated recommendations as to whether or not to get the test / procedure. That recommendation would be based upon expert opinion based upon the literature. It would be the standard of care and so would reduce liability whether there is medical malpractice reform or not. Just to be clear. Just because there would be these automated recommendations, physicians and patients should always make the final call.

    Additionally, I would like to see everyone receive a set amount towards an MSA. If they spend less now then it builds up in a retirement account. In particular, if patients take care of themselves (such as lifestyle) then they may end up a nice supplemental retirement account.

    As for care providers, there should be a mechanism to balance incentives to do the correct thing for patients, practice cost-effective medicine, and liability for bad outcomes. Right now it is significantly skewed.

  3. Why Medicaid recipients do worse isn’t entirely clear

    Really? Adult Medicaid recipients are by definition disabled and/or impoverished. They’re on Medicaid precisely because they’re “doing worse”.

    1. Um, Jim, I thought the exact same thing. People on Medicaid are from “the mean streets” so they have two strikes against them in terms of general health, well-being, and even in terms of following that complicated sheet of instructions you get sent home with after a visit to the ER or Urgent Care.

      But the article states, “And these findings hold up even when you correct for age and socioeconomic status.”

      Yes, it is called “experimental control.” I know what you are thinking because I was thinking the same thing. How good was the experimental control on those studies, did they really rule out that Medicaid starts with a “patient in worse condition” than the wealthier people with better health care plans? But the article claims that they did control for those factors.

      But maybe it is odd that the Libertarians ’round here are disrespecting Medicaid . . . for underreimbursing doctors. You would think that the Libertarian position would be what you are arguing, that poor persons make poor students, poor workers, and poor patients and that it is not the fault of the doctors and that the government isn’t spending enough money on Medicaid to properly treat its patients?

      1. Controlling for age and socioeconomic status really isn’t enough. You can have low income because you’re going to grad school full time, or low income because you were born with severe birth defects, or low income because you were in a car accident and are now a quadriplegic. Those last two situations will qualify you for Medicaid, but it’s no surprise that you won’t be as healthy as the grad student, and it isn’t because only bad doctors take Medicaid! Medicaid is also what people turn to when they need years of expensive nursing care for problems like Alzheimer’s, and they’ve run through all their savings. The Medicaid patient in a nursing home is not going to be as healthy as some random person of the same age and income. Most adults on Medicaid don’t have it because they’re poor — they have it because they have health problems.

        The best-controlled study on this subject was done in Oregon — they had n Medicaid applicants but only enough money for m of them (n > m), so they had a random lottery, and later could compare the two populations. Unfortunately the sample size was small, and the study didn’t last very long, but all the same after two years the people who got on Medicaid were doing significantly better than the people who weren’t picked, particularly with mental health.

        It’s honest to say “I don’t want the government to take my money to pay for health insurance for poor and disabled people.” It’s disingenuous to pretend that the problem with giving health insurance to poor and disabled people is that it’s harmful to them.

        1. The implication I drew from the article is that Medicaid is bad for people because it is badly underfunded.

          Am I to draw the inference that you are arguing that Medicaid is helping people and that it is receiving a sufficient level of funding that it is a net benefit?

          1. Yes, it’s a net benefit to the recipients, but a lot of people who qualify don’t get it. Proving eligibility is a bureaucratic obstacle course, and while the ACA goes a long way to help that, Medicaid expansion is only happening in about half the states.

  4. DougSpace:

    Think of this from the patient’s perspective. I hit my head real bad and I have a splitting headache, blurred vision, light sensitivity.

    The deal is that I am taking a risk if I don’t go to the doctor, but I am not “overutilizing medical resources” if I have “good insurance” or incurring a huge bill if I don’t. Most likely I have a concussion, but there is not much in the way of treatment apart from, dunno, don’t fall asleep in the first 12 hours? Refrain from activities and rest until these symptoms clear up?

    So what does the CT show you that the neurological exam doesn’t? That there is some big bleed under the skull that needs an emergency craniotomy?

    If I take the risk upon myself and don’t show up at your clinic and die or become paralized, this is my personal decision. If I think that I was konked real good and show up in your clinic, now you are involved, with your medical license, your exposure to liability, with your dedication to your profession and your “do no harm” oath, which could include harm of omission of not ordering a costly test?

    So is a cost decision even on the table, if I tell you that I don’t want to spend a lot of my own money, or I hint that “I think I am OK” and don’t want whoever is funding the health insurance to spend a lot of money. If I thought that way, I shouldn’t have stepped across the threshold to your clinic because as soon as I do, certain considerations kick in?

    1. So is a cost decision even on the table, if I tell you that I don’t want to spend a lot of my own money, or I hint that “I think I am OK” and don’t want whoever is funding the health insurance to spend a lot of money. If I thought that way, I shouldn’t have stepped across the threshold to your clinic because as soon as I do, certain considerations kick in?

      I’d say “yes” a cost decision is always on the table.

      1. I was wondering what “DougSpace” had to say on this question. Once you submit yourself to the care of a doctor, it is on the doctor’s conscience, record, liability insurance, training, sense of compassion, professional reputation, and the doctor will bring their skills of persuasion and being the white-coat authority figure to get you to agree to that CT scan on the off chance that you have, do they call it a subdural hematoma, requiring emergency surgery that you either live or don’t live the rest of your life profoundly crippled.

        C’mon now. In this hypothetical case, you have already done something stupid to get a blow to the head. You already have alarming symptoms that you have gone to the clinic or the paramedics picking you off the pavement from your crashed bicycle have “taken you in”, and you are going to start arguing with the doc, “I got one of those ‘Obamacare Bronze’ plans where this CT scan is going to be thousands of dollars out of pocket and I have already maxed my credit card. You think you could let me go home and if I start dry heaving, my roommate Fred over in the waiting room will bring me back in”?

  5. Medicaid is a free-market solution.

    If you get medicaid you can go anywhere you want that takes medicaid and
    get treated.

    The Feds don’t own the hospitals or the doctors, Medicaid is a single payer option.

Comments are closed.