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.
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