By John Daniel Davidson
Thursday, June 29, 2017
Remember Deamonte Driver? He was the 12-year-old who died of a toothache in 2007. The boy lived in Maryland and was enrolled in that state’s Medicaid program, which covers dental care for children, as all Medicaid programs are required to do.
But Deamonte’s mother couldn’t find a dentist who would take Medicaid. At the time, only about 16 percent of Maryland dentists accepted Medicaid patients, and Deamonte was in dire need of basic dental care—as was his younger brother, DaShawn, who had six rotted teeth.
By the time Deamonte’s toothache got attention, bacteria from an abscessed tooth had spread to his brain. He underwent two emergency operations and six weeks of hospital care that cost more than $250,000. But it was too late, and Deamonte died. A routine, $80 tooth extraction could have saved his life.
Deamonte’s case prompted a national conversation about Medicaid. How had Maryland’s Medicaid program so thoroughly failed the Driver family? Why hadn’t they been able to find a dentist? And what is the point of being enrolled in Medicaid if there are no doctors or dentists willing to treat you?
Those questions were never really answered, but they’re as pertinent today as they were a decade ago—arguably more so, since we’re once again engaged in a national debate over health care reform and the fate of Obamacare’s Medicaid expansion. Then as now, the reality is that Medicaid doesn’t save lives. In some cases, like Deamonte Driver’s, it bars access to basic life-saving treatments.
Coverage Isn’t The Same As Care
Not that Democrats are going to let that get in the way of some rousing hyperbole. Amid the back-and-forth this week over the Republican health-care bill in the Senate, leading Democrats and their courtiers in the media predictably took to denouncing any GOP rollback of Medicaid expansion as an evil scheme that will ruin millions of lives and kill thousands of Americans.
Vox warned that the GOP plan would kill more Americans each year than gun homicides do—that’s a death toll of more than 24,000 on Republicans’ hands. Sen. Bernie Sanders claimed Sunday on NBC’s “Meet the Press” that “thousands will die” if the Republican proposal is passed (PolitiFact rated this as “mostly true”). The Center for American Progress did some back-of-the-envelope calculations showing that Senate Republicans’ health-care bill will lead to 217,000 more deaths over the next decade. Scary stuff indeed.
Proponents of the “thousands will die” argument cite evidence that health insurance is correlated to health outcomes, which is a fair point, as far as it goes. But they too often conflate health insurance with Medicaid coverage. That’s important for two reasons: 1) the majority of coverage gains under Obamacare have come from Medicaid expansion; and 2) Medicaid coverage isn’t the same as private insurance—not even close. When progressives talk about insurance under Obamacare, they’re mostly talking about Medicaid coverage, not private health insurance.
The distinction is important because research has shown that being on Medicaid produces no better health outcomes than being uninsured. This argument has been hammered home by conservative health care scholars like Avik Roy and others, much to the consternation of progressive health policy wonks, who insist on torturing otherwise decent studies for signs that Medicaid saves lives.
For example, a much-cited 2008 study of Oregon’s Medicaid program found no difference in health outcomes between a group enrolled in Medicaid and a control group of the uninsured. Obamacare proponents will cry foul if you cite these findings, and counter that the researchers also found that Medicaid enrollees enjoyed better mental health and more financial security.
Of course they did—even the authors of the study noted as much. That’s what you’d expect from a group of people who can visit a doctor or hospital virtually free of charge. (Although the claim of improved mental health is dubious, since two-thirds of the improvement in self-reported mental health occurred before enrollees had consumed any medical treatment.)
What Medicaid expansion boosters don’t like to talk about is how the Oregon study found that Medicaid enrollees dramatically increased their visits to the emergency room compared to those who were uninsured. One of the flawed assumptions behind Medicaid expansion was that new enrollees would seek care in the most cost-effective outpatient settings instead of going to ERs, which are required by federal law to treat anyone in medical need. But the opposite happened.
How Medicaid Fails The Poor
What accounts for these findings? Part of the answer brings us back to Deamonte Driver. Simply put, too few health care providers participate in Medicaid, so Medicaid patients often have an extremely narrow network of care—especially specialist care. That’s why they often end up in expensive and inefficient hospital ERs.
This flaw is built into Medicaid’s design. Like Medicare, Medicaid pays less than private insurance does, so doctors and dentists are often hesitant to take on more than a handful of Medicaid patients, which means there simply aren’t as many doctors and dentists available to see Medicaid patients as privately insured or self-paying patients. What’s more, Medicaid enrollees don’t even have the option of paying the difference between what Medicaid pays and what private insurance pays, or negotiating the kinds of payment plans most providers are happy to offer low-income patients. Federal Medicaid rules simply won’t allow it. It’s either all Medicaid, or nothing.
Progressives have never wanted to admit any of this, or face the stark reality of Medicaid’s failures. That’s why they trumpet Obamacare’s Medicaid expansion as a success, and elide the gap between coverage and care. Ezra Klein, writing about Obamacare and the plight of the uninsured in 2011, invokes Deamonte Driver but fails to mention he was enrolled in Medicaid. “If he’d had an Aetna card,” wrote Klein, “a dentist would’ve removed the tooth earlier, and the bacteria that filled the abscess would never have spread to his brain.”
But he didn’t have Aetna. He had Medicaid. And that made all the difference.