Is Medicaid's Access Problem Fictitious? Not really

In a report that is sure to be misused and abused by those championing states' Medicaid expansions, the Government Accountability Office (GAO) announced that based on their survey of the states, and an analysis of national expenditure data, Medicaid beneficiaries have no more trouble accessing medical care than those on private insurance. If true, this finding would dispel the notion that cutting provider payments creates access problems. The problem isn't with GAO's report or methodology - it's with people that will only read the top-line heading and run with it.

The report found that among Medicaid beneficiaries who had full-year coverage, differences in those reporting problems with access to care were not statistically significant. Specifically: 3 percent of those with private insurance had difficulty with access to medical care, compared to 3.7 percent of those with Medicaid; 2.4 percent of those with private insurance had difficulty with access to prescription medicine, compared to 2.7 percent of those with Medicaid; and 3.7 percent of those with private insurance had difficulty with access to dental care compared to 5.4 percent of those with Medicaid.

Thumbnail image for gao_difficulty_care.png

According to GAO's methodology, the confidence interval for these estimates is about ±1.5, which makes only differences in dental care access problems statistically significant for those with a full-year of insurance.

If this was all that GAO reported, it would be fair to say that Medicaid has no access problem compared to private insurance.

It isn't.

First off, GAO notes that across the years they analyzed, more states increased payment rates for providers than the number that reduced them - this would mitigate the access problem to an extent.



Note: some states increased payment for some providers, cutting payments for others; totals don't add up to 50.

Where Medicaid's access problems show up, however, is in GAO's analysis looking at working-age adults and whether coverage was maintained for a full-year or less.


The difference between those with private insurance and Medicaid is astounding. While only 3.3 percent of those with full-year private insurance had access problems, a full 7.8 percent of those with full-year Medicaid coverage had access problems. Even the uninsured who had coverage for part of the year fared better than those with partial-year Medicaid coverage; the difference between them and those who had Medicaid coverage for a full-year was statistically insignificant. (The confidence interval is ±1.7 for this sample.)

Finally, waiting times were a significant problem for those with Medicaid (9.4 percent versus 4.2 percent of those with private insurance versus 6.8 percent of those who were uninsured).

The reality is that the GAO report merely reinforces what should be common sense about Medicaid - if you pay providers less than private insurance, you will encounter access problems. But it also indicates that there is something systemic about younger (under 18) and older (over 65) patients that causes them to have fewer access problems than working-age adults, even with Medicaid. The aggregate numbers presented earlier in this post include children covered under Medicaid and Medicare/Medicaid dual-eligibles (seniors who qualify for Medicaid and Medicare). Children are likely will be healthier and will likely be seeing a care provider for more routine causes like a checkup or a flu shot. Because these are more routine, less expensive procedures, it will be easier to find a provider. For dual-eligibles, Medicare would cover many routine procedures; because of its higher reimbursement rate compared to Medicaid, access problems would be mitigated. As a report from MedPAC in 2004 confirms, dual-eligibles generally have good access to care, and those with supplemental insurance, even better.

GAO's findings should make states question whether to expand their Medicaid programs as they are - particularly when outcomes, relative to private insurance and even no insurance, are questionable. Avik Roy, at the Apothecary has written extensively about this. To be fair, Austin Frakt at The Incidental Economist has pointed out repeatedly that outcome-based measures in Medicaid don't necessarily imply causation and could very well be a product of self-selection into the program.


This isn't correct:
"While only 3.3 percent of those with full-year private insurance had access problems, a full 11.9 percent of those with full-year Medicaid coverage had access problems. "

Take a look at your chart, the 11.9 refers to individuals who were covered by Medicaid for only a partial year. 7.8 percent of those with full year Medicaid reported difficulties.

Point taken

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