JAMA Forum: Is Medicaid Expansion Like a Silver Bullet for Improving US Health Care?

Image: Thinkstock/designer491

Health care policy in the United States suffers from a bad case of “silver bullet-itis.” There always seems to be an acronym or catchphrase around the corner to rescue us from the high costs, bad outcomes, and disjointed and angst-filled set of experiences with the health care system. For example, ACOs (accountable care organizations), value-based benefits, transparency, AI (artificial intelligence), and EMRs (electronic medical records) come on the heels of the last set of temporary saviors. Remember PHRs (personal health records), consumer-driven health plans, big data, PPOs (preferred provider organizations) and their cousins HMOs and EPOs (health maintenance organizations and exclusive provider options)?

When even promising ideas don’t turn into instant miracles, they become dispiriting. Our fascination with finding silver bullets creates a cycle that zaps the very attention span we need to do the actual work to fulfill some of the promise of new ideas. In that way, silver bullet-itis is a corrosive and self-defeating habit. So, let’s be clear. There are no silver bullets.

But wait—not so fast.

A series of new studies being released with increased frequency are all starting to point to a single action that is behind a growing list of amazing things: reducing mortality from at least 2 of our biggest killers, cardiovascular disease and cancer; addressing seemingly intractable racial disparities that plague the US health care system; reducing hospital bad debt and rural hospital closures; decreasing maternal and infant mortality; lowering payday lending and housing foreclosures; creating jobs and improving financial health; improving medication compliance; and lowering the cost of insurance.

That action? Passing and implementing Medicaid expansion.

One study published in JAMA on June 5 by Ahmed Khatana, MD, of the University of Pennsylvania, and colleagues shows that even after adjusting for economic, clinical, and demographic differences, there are 4.3 fewer cardiovascular deaths per 100 000 residents in Medicaid expansion states. This is on the heels of a study published a few days earlier in the American Society for Clinical Oncology that had the rather headline-grabbing finding that Medicaid expansion erased the disparities in cancer care between white and African American patients.

The studies are amazingly consistent and amazingly positive. In a country facing year-over-year declines in life expectancy and widening health disparities, this may be the closest thing to an actual silver bullet.

Medicaid Expansion and the Triple Threats
Researchers also have found evidence indicating that Medicaid expansion has improved consumer financial outcomes as well as health outcomes. For example, one study showed that Medicaid expansions significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies among those living in areas with a high proportion of low-income individuals who lack health insurance, while another found that expansion reduced unpaid medical bills sent to collection, prevented new delinquencies, and improved credit scores.

The clear and convincing benefits of Medicaid expansion should have made it ubiquitous by now. But it is caught in the pushes and pulls illustrated by what I described in a prior JAMA Forum as the Triple Threats of health care reform against achieving the Triple Aim. The latter, the guiding light of US health policy in the last decade, is enhancing the experience of care for the patient, improving the health of populations, and reducing the per capita costs of health care. The Triple Threats are the 3 things that stand in the way of achieving the Triple Aim: our large and growing health disparities, our system’s obsession with revenue, and the poisonous nature of the politics that surround health care.

Medicaid expansion helps address the first 2 of those threats. Expanded Medicaid makes a dent in the seemingly intractable inequities of health care outcomes and reduces the need for more costly downstream care. The state of Louisiana publishes publicly the thousands of screenings and diagnoses for breast cancer, colon cancer, hypertension, and mental health since the state expanded Medicaid. Life by life, you can see the difference.

Medicaid expansion also provides payments in a way that more closely aligns with the outcomes we want. Without Medicaid expansion, uninsured patients and even those with high-deductible insurance avoid needed care and most care providers can’t afford the bad debt. Tax payer–funded uncompensated care pools, which are intended to make up some of the difference, are lump-sum payments detached from accountability for patient care and outcomes. But Medicaid expansion gives patients an actual insurance card with comprehensive benefits. And because of its too-modest-payment rates, it encourages early detection and diagnosis rather than a costly traditional fee-for-service scenario. In effect, Medicaid is population health without the fancy payment models.

But if Medicaid expansion shows us a way to get past the first of the 2 Triple Threats, it’s also an illustration of the intractable nature of how health care politics, the third threat, gets in the way of good policy. Fourteen states, including Florida and Texas, have, to date, still decided not to expand Medicaid. Nearly 4 million people stand to gain comprehensive coverage and a new lease on life in those states. But silver bullet or not, Medicaid expansion is tied to Obamacare, and that label is still an unfortunate liability in states with Republican governors and legislatures. Health care politics aren’t serving us well when they get in the way of good policies, do not match with public sentiment, or—in this case—both.

Medicaid expansion is very popular with the US public, possibly because of the clear benefits. Several states that hadn’t expanded Medicaid on their own recently passed ballot initiatives that went overwhelmingly in favor of Medicaid expansion. Even in conservative states, Medicaid expansion is overwhelmingly popular and has the support from many who don’t expect to directly benefit themselves.

Yet in one of those states, Utah, the legislature voted to reverse course even with Medicaid expansion’s overwhelming support. The partisan politics were so powerful that the state even decided to spend more money to cover fewer people than the voters supported. Politics that don’t serve the public are a greater threat to progress than traditional culprits like costs.

We don’t have many things we can do that are a surefire way of improving our health care system. Expanding Medicaid in remaining nonexpansion states is one of them. Even for those of us wary of silver bullets, it’s nice to find one.


About the author: Andy Slavitt, MBA, Founder and Board Chair of United States of Care, served as the Acting Administrator for the Centers for Medicare & Medicaid Services under President Obama from 2015 to 2017, where he focused on advances in health care coverage and accelerating health care delivery system transformation. He has 2 decades of private–sector health care leadership, both as a senior executive at Optum, a health services and innovation company, and as an entrepreneur. He tweets at @ASlavitt. (Image: US Department of Health and Human Services)



About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Categories: ACA, Caring for the Uninsured and Underinsured, Health Policy, Medicaid, The JAMA Forum

Tags: , , ,