Medicaid expansion is one of the critical pillars of the Affordable Care Act (ACA). Since the passage of the ACA, Medicaid expansion has been a Democratic priority, but Republicans are now warming to the idea in some states that have previously resisted expansion. North Carolina is one of 12 states that have not expanded Medicaid, and there are currently proposals in both chambers of the General Assembly proposing such an expansion.
I can offer the front-line view as a physician. I spent over 20 years working as an emergency physician. I continue to see patients, though my professional efforts are now directed toward providing patients with more freedom and choice in their health care decisions. In emergency medicine, I saw the many dysfunctions of the health care system, which are often devastating for the health of patients’. I am acutely aware of the gap between the promises of politicians and the behavior of a complex system in the real world.
The argument favoring expansion is straightforward — more people get health insurance coverage, and the federal government pays for most of it. Opposing views are well-documented, and I refer the reader to the excellent article by Brian Blasé. Briefly, those arguments are 1) Medicaid expansion will impose a burden on state budgets that cannot be sustained without displacing other priorities; 2) at least 20% of current Medicaid spending is due to fraud and waste, which will not improve with expansion and is unconscionable regardless of which taxpayer pocket the money is taken from; 3) expanding Medicaid to able-bodied adults will displace people from private insurance to an inferior product; and 4) those with Medicaid have reduced access to care and receive lower quality care than those with private insurance. I will focus on this last point here.
In considering Medicaid expansion, it is essential to recognize that insurance coverage is not health care. On top of the overall shortage of health care providers, a recent survey found that only 53% of physicians accept Medicaid. Studies have documented that this translates into long waits for care. No matter how often I advise a patient to get a primary care physician to help them keep their blood pressure or diabetes under control, many times, they simply cannot get an appointment. Referrals to specialists are often based on hopes and prayers. Red tape, poor payment rates, and bureaucratic inflexibility mean that accepting Medicaid is not worth the hassle for physicians. Expanding Medicaid will not change this dynamic and will likely worsen it.
If having Medicaid improves health, the experience of states that have expanded Medicaid should make it easy to demonstrate that. But studies show that having Medicaid confers no consistent health benefit. Oregon performed a unique experiment in 2008 when it held a lottery to fill available Medicaid expansion slots. Then, it followed applicants and compared the health measures of those who “won” the lottery to those who did not. The study showed no health benefits to winning the Medicaid lottery.
Other studies have shown that Medicaid patients with some conditions die at higher rates than those with private insurance and, in some cases, even higher than those without insurance. I am aware of no studies that demonstrate improved care for those on Medicaid relative to private insurance. Those on the front lines of health care understand that quality is a function of the performance of an entire system rather than of an individual. The data tells us that the system does not perform well when Medicaid is the payer. This should not surprise us since it is consistent with our common experience comparing services provided by the government vs. the private sector.
My opposition to Medicaid expansion is shaped by how I see it playing out in the real world for patients. The fundamental dysfunction of our health care system is that health care is unresponsive to patient needs and just too expensive, no matter who is paying the bill. A functioning market is the only force to make health care (or any service) accessible, affordable, and high-quality. Many options available to state policymakers would increase market forces in health care. Policymakers should consider market-oriented policy solutions rather than doubling down on a solution that has been found lacking in every way that matters. Shouldn’t we expand the things that work rather than a program that has never worked well?
Dr. Sonny Morton is a physician with extensive experience in emergency medicine.