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Both Sides Cite Oregon Study in Medicaid Expansion Debate Despite Inconclusive Data

May 10, 2013 by Leave a Comment

The New England Journal of Medicine published an analysis of the effects of Medicaid coverage, and it’s no surprise that both sides of the Medicaid expansion debate claimed to have found support for their positions. Opponents of the health reform legislation, and the Medicaid expansion in particular,  argue, “See? We told you Obamacare won’t work.” Proponents look at the same data and say, “Medicaid works.” And some observers see that each side is only focusing on one aspect of the data.

What exactly did the results show? Two years after winning the lottery, the Medicaid beneficiaries had gotten more preventive screenings, were more likely to have been diagnosed with diabetes and to be on medication for it, they reported less depression and were free of the strain of medical debt. But there were no significant differences in blood pressure, cholesterol levels, or glycated hemoglobin between the two groups. The same percentage of subjects in each group had glycated hemoglobin levels exceeding 6.5 percent, which would signify diabetes.

Apparently, the investigators had hoped for a demonstrable improvement in physical health, and the results didn’t support that interpretation. The authors and others have offered several possible explanations for this unexpected result.

  • Having Medicaid doesn’t eliminate all barriers to access to care
  • Medicaid beneficiaries get poorer quality health care than either the privately insured or the uninsured because of the low reimbursement rates
  • It takes time for the effects of preventive care to become apparent
  • “Lifestyle” changes are necessary to lower blood cholesterol or blood pressure, and it is hard to quit smoking, change one’s eating habits, and exercise.

Isn’t elimination of crushing medical debt are the purpose of health insurance, including Medicaid? It stands to reason that  removing the debt would decrease the likelihood of depression. And it’s well established that one’s state of mind is an important factor affecting one’s physical health.

In Forbes, Avik Roy compared the Oregon Study to the kind of clinical trial that the Food and Drug Administration would require to test a new drug. The study was flawed because it wasn’t double-blinded, meaning that the subjects knew whether they were on Medicaid. And there wasn’t a specified endpoint, a specific result that would show whether the medication was effective at treating the disease.  Is that a fair comparison? The investigators took advantage of an opportunity to see what happened when some people on a waiting list had the chance to apply for Medicaid and others did not. But what the two groups had in common was poverty, not any particular medical condition.

In the aggregate, the lottery winners and the control group were similar demographically. But that doesn’t mean they all started out in the same state of health.  To look for changes in the clinical conditions, the investigators focused on the subjects who reported having a diagnoses of hypertension, diabetes or high cholesterol before March 2008, when the first lottery was held. The  subjects who were chosen in the lottery, applied, and were found eligible for Medicaid may have been more motivated to follow through because they had a greater need for health care. To know what difference Medicaid made in the lives of beneficiaries, it would be useful to know how many of them were newly diagnosed with hypertension, diabetes, or high cholesterol during the study period. The investigators also asked about diagnoses of asthma, but the analysis of that data has not been published.

The results at two years are based on interviews held between September 2009 and December 2010. The average length of time on Medicaid was 17 months, not two years. Not all the Medicaid beneficiaries stayed in the program for the entire two years, and we cannot assume that everyone in the control group was uninsured for the entire time, either. The study documentation states that some of the people in the control group got Medicaid benefits through a later lottery. The article states that winning the lottery increased a subject’s chances of having Medicaid coverage by about 25 percent.  Apparently, the population who actually got Medicaid after winning the lottery was not as similar to the control group as the larger group of lottery winners, so the investigators used winning the lottery as the “instrument” for Medicaid coverage.  In other words, many people in the “Medicaid group” actually did not receive Medicaid coverage; if that is true, it’s no surprise that Medicaid coverage had little effect. The investigators’ plans for further analysis will focus more closely on the group who enrolled in Medicaid.

Filed Under: Health care spending, Medicaid, Medicaid, News, Patient Protection & Affordable Care Act

HHS Hangs “Welcome” Sign on Doorway to Health Care

May 1, 2013 by

Next year, 15 million currently uninsured Americans will be newly eligible for Medicaid coverage.  Low-income women, men and children from a variety of backgrounds will have access to health care, and under the new guidelines put forth by HHS’ Office of Minority Health, the current administration is making it clear that all individuals, no matter what ethnicity, sexual orientation or cultural background are welcome.

HHS announced the release of a promising set of updated cultural policies and principles to help providers better relate to minorities, address their care needs, and ultimately reduce health disparities. Many groups view this update as a major milestone in the implementation of the HHS Action Plan to Reduce Racial and Ethnic Health Disparities, as well as a step towards equality in health care.

HHS’ policy update, referred to as the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, or CLAS Standards for short, is a set of guidelines to help provider practices relate culturally and provide linguistically appropriate health services. The enhanced National CLAS standards recognize health as being influenced by factors ranging from race and ethnicity to language, spirituality, disability status, sexual orientation, gender identity, and geography.

“We are making great strides in providing quality care and affordable coverage for every American, regardless of race or ethnicity or other cultural factors because of the Affordable Care Act,” said HHS Secretary Kathleen Sebelius as the release was announced. “The Enhanced National CLAS Standards will help us build on this ongoing effort to ensure that effective and equitable care is accessible to all.”

The update is well regarded among various organizations representing several groups. ThinkProgress posted a blog on the benefits to the lesbian, gay, bisexual and transgender (LGBT) community. The blog noted that included in the policy are recommendations made by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in its field guide “Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care,” which provides guidance for incorporating the concerns of the LGBT community into the framework of culturally and linguistically appropriate care.

HHS updated the CLAS standards in response to changing demographics of the country and the growth of linguistic competency, and to ensure the relevance and applicability of the standards. This way, everyone will feel welcome and seek the care they need. In return, providers will be ready and able to respond.

“Many Americans struggle to achieve good health because the health care and services that are available to them do not adequately address their needs,” said J. Nadine Gracia, MD, MSCE, Deputy Assistant Secretary for Minority Health and Director of the HHS Office of Minority Health. “As our nation becomes increasingly diverse, improving cultural and linguistic competency across public health and our health care system can be one of our most powerful levers for advancing health equity.”

Filed Under: Health Insurance Exchange, HHS, Medicaid, Medicaid, News, Patient Protection & Affordable Care Act, Uncategorized

Per Capita Caps for Medicaid: Help, Hindrance, or Middle Ground?

April 24, 2013 by

Medicaid per capita caps, a proposed reform to Medicaid that would limit the amount of federal spending per beneficiary, may provide help to control the growth of federal spending on Medicaid, according to its supporters. However, some argue that instead of slowing the rate of spending growth, it would only shift the costs to the state, ultimately limiting poor Americans’ access to care. A recent health policy brief by Health Affairs and the Robert Wood Johnson Foundation examined this proposed “per capita cap” on federal Medicaid funding, in an attempt to determine whether it might be the key to controlling costs.

According to the brief, Medicaid spending is expected to grow to $795 billion by 2021, almost doubling from the $432 billion spent in 2011. Much of this growth in spending can be attributed to the Patient Protection and Affordable Care Act, which substantially increases the number of individuals eligible for Medicaid. Further, the federal government plans to cover 100 percent of expenses for the newly-eligible enrollees for the first few years, and then decrease that coverage to 90 percent. Covering more people costs more money, and concerns over the program’s costs at both the federal and state levels have led some policy makers to urge reforms.

Per Capita Caps Defined

One proposal to curb costs is to impose a per-beneficiary cap. Under the proposed Medicaid “per capita caps,” the federal government would no longer cover a fixed share of each state’s overall Medicaid costs but instead would limit each state to a fixed dollar amount per beneficiary. To calculate the cap, total spending and the total number of beneficiaries would each be calculated for a given base year. Then, the number representing total spending would be divided by the number of beneficiaries to calculate the initial amount spent per person, or per capita amount. This per capita amount would be adjusted annually for inflation, by some measure such as the consumer price index. Once the per capita cap is arrived at, it would be multiplied by the number of beneficiaries in the program.

Cost Control Theory

Using the per capita cap, total Medicaid spending would only increase as enrollment increases, which would give states an incentive to control other factors that lead to increased spending. Using Medicaid per capita caps is not a new idea, in theory or in practice. They are in place as an integral part of many demonstration projects as a means to control costs, and they were also part of President Bill Clinton’s budget proposal in 1997; however, they were not used.

Reluctance to Change

Despite the theory on cost control, the reluctance to move to a capitated model clearly still exists. Although many believe that the per capita cap approach would provide an incentive for states to be efficient, others question whether a per capita cap would truly save the federal government money. This is because much of the growth in Medicaid spending in the past ten years is due to increases in enrollment and less for increases in cost.

Causes for Concern

Many critics are concerned over problems inherent in determining the cap, such as population, base year and inflation. There are substantial differences in the cost of providing care to children versus adults, the elderly or the disabled. Whether the per capita cap would break the population down into various subgroups remains in question. The selection of a base year from which to develop the per capita cap cost would also be very important. Using this method, a combination of the enrolled population, payment rates, and covered services in the base year would determine how much spending would be available in future years. Spending levels from a base year marked by recession would likely reflect a narrower range of services or lower payment rates, but setting a base year during a time of improving economic conditions could well reflect more generous benefits and higher payment rates. And finally, the method used to mark inflation also gives critics pause. Both gross domestic product (GDP) and the consumer price index (CPI) are typical measures used to account for inflation. However, given that health care costs typically rise faster than either one, neither may sufficiently cover costs.

Future

Overall, whether a Medicaid per capita cap will emerge as part of entitlement reform efforts is unclear. The brief noted that per capita caps are a part of the discussion but have yet to make it into any sort of reform.

Filed Under: Centers for Medicare and Medicaid, Health care spending, HHS, Medicaid, Medicaid, News, Patient Protection & Affordable Care Act
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