Ebook , by Avik Roy
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, by Avik Roy
Ebook , by Avik Roy
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Product details
File Size: 264 KB
Print Length: 48 pages
Publisher: Encounter Books; 1 edition (November 12, 2013)
Publication Date: November 12, 2013
Sold by: Amazon Digital Services LLC
Language: English
ASIN: B00FIP4CGK
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Roy begins with the 2006 story of 7th-grader Deamonte Driver, who died of a toothache in one of the wealthiest counties in America. Several months after Deamonte complained of pain, his mother was able to find a dentist that would see him. After being told he needed to see an oral surgeon, several more months passed by before he could be seen Meanwhile, the infection from one of his abscessed teeth spread to his brain. Despite emergency brain surgery, Deamonte died - despite being on Medicaid.Medicaid cost over $450 billion in 2013. Study after study shows that patients on Medicaid do no better, and often do worse, than those with no insurance at all. Medicaid was burdened by the stigma of public assistance and allowing states to decide how extensive their programs would be.The percentage of Medicaid spending that the federal government will sponsor varies depending on the relative wealth of a given state. Washington provides 73% of Medicaid funds in Mississippi, 50% in the wealthiest states such as New York and Massachusetts. The median state is funded at 60%. To keep Medicaid costs in check, some states pay hospitals and doctors less. A total of 39 states restricted provider rates in fiscal year 2011, and 46 states reported plans to do so in fiscal year 2012. The average state pays a primary-care physician 52 cents for every dollar that a private insurer pays. New York and Rhode Island pay 29%, New Jersey 32%, D.C. 38%, Minnesota 46%, and Michigan 47%. Thus, primary-care doctors are 73% more likely to reject Medicaid patients relative to those who are privately insured, and specialists were 63% more likely. In New Jersey, 60% of physicians were unwilling to accept new Medicaid patients, California 43%, and New York 38%.A 2011 study found that doctors asked for appointments for a child with acute asthma attacks or a broken forearm would deny an appointment 66% of the time, vs. only 11% if told the patient had private insurance. Average wait time for an appointment was 22 days longer.In the early 2000s, Oregon had randomly offered Medicaid coverage to 30,000 residents, leaving tens of thousands still uninsured. By tracking these new patients over time, it was possible to assess whether or not Medicaid was making its enrollees healthier. In 2011, economists who were studying this released their initial findings. While too early to measure effects on objective health measures, patients told the researchers they felt better. However, the study did not detect any change in mortality. However, the researchers also noted that two-thirds of the improvement in patients' self-reported health took place 'about one month after coverage was approved' but before the patients had seen a single doctor or consumed any health care services. When the following July came around and it was time to publish the two-year results, the researchers were silent. Finally, on 5/1/2013, the NEJM published the findings. It had generated no significant improvement in measured physical health outcomes. Further, out of the 35,169 individuals who 'won' the lottery tot enroll in Medicaid, only 60% actually bothered to fill out the application and only half those who applied end up enrolling.Turns out that the real benefit is that health insurance protects policy-holders from catastrophic financial loss - like fire and auto insurance.Concierge doctors in the Epiphany Health Plan charge $80/month, whether you see them or not, with spouses another $69/month and $49/month for each child. That would eliminate the need to search for a provider when someone of little means needs care. The dirty secret of Medicaid is that they clog emergency rooms because they can't persuade regular doctors to see them. The author proposes giving every Medicaid patient the Epiphany plan, plus a $2,500/year catastrophic plan to protect against financial ruin. The total annual cost would be $3,460/person, 42% less than what Obamacare's Medicaid expansion costs.
The book is basically a lit review of a number of studies showing the lack of efficacy of medicaid In order to prove a case for reform. Unfortunately, Roy doesn't go into the details of the methodologies of the studies, nor does he present and discuss studies with which he disagrees. For example, Roy refers to (I won't say cites because he provides no footnotes or bibliography) many studies showing medicaid patients are worse off than those without health insurance. However, much of the medicaid population is sicker/leads less healthy lives, etc. Roy accounts for this with a single sentence saying that the studies "controlled" for this, but offers no details. How is the statistical power of the study affected? What are the confidence intervals of the results? In the Oregon study, only 60% who won the lottery took the medicaid. Why? Likely it's because the other 40% were reasonably healthy and they saw no benefit. Therefore two conclusions could follow: 1) The customer service of medicaid is sufficiently poor that it's not worth signing up for the free program if one is healthy and 2) the people who would go through the trouble of signing up are sufficiently sick to be motivated to do so. Given this, it would naturally follow that medicaid patients would have worse outcomes, especially given the restricted networks and poor reimbursement rates Roy details.All in all, it's a missed opportunity for a dive into the details. The result makes the book a one sided argument not very likely to convince believers in the medicaid model that it's so fundamentally broken.
I'm reading Avik Roy's book (pamphlet) on Medicaid. I have some strong opinions on this topic. In 1965, when Medicare and Medicaid became law, I was a medical student at the Los Angeles County Hospital. My experience has been that the big city hospitals that once served as the safety net for the urban poor, were devastated by the new law. Medicaid (MediCal in California) would not pay for care in the County hospital where resident physicians were often the providers. I knew men who quit their residencies to start MediCal mills.Years later, after I had done a graduate program at Dartmouth, I asked permission of the new MediCal administrator to study the results of an HMO model versus a fee for service model. I had the funding and the academic support. Permission was refused.The author does an excellent job of describing the evolution of Medicaid and the effects on the poor. I have never changed my mind about the benefits of the previous model, using big community teaching hospitals to treat the poor. Medicaid promised them "mainstream private care" which they have never had and will not have under Obamacare. Many primary care docs I knew when I was in practice would treat Medicaid patients and never bill the system because the payment was so poor and it took two years to get paid. They were in practice in a prosperous community. Many inner city docs had no choice but were unable to provide good quality care. Medicaid was never a real choice for the poor.Good account and well worth reading. His last section advocates a free market system for the Medicaid population. I tend to doubt its efficacy and think the basic safety net would be stronger in a system that included teaching hospitals and clinics. There is a reason most poor people are poor. For years after Medicaid began we would get patients coming to the County Hospital clinics for a second opinion, then going back to the private second rate hospital because of the amenities. They trusted us but liked the semi-private room.
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