No Difference Between Public & Private Coverage

A new study confirms what many think, that some insurance coverage is better than none. What may challenge some people’s preconceptions is that whether that insurance coverage is private or public (i.e. Medicare or Medicaid) access to care is fairly similar.

Researchers assessed the healthcare landscape in Texas, Arkansas, and Kentucky – three states with dramatically different approaches to the Affordable Care Act (ACA). They explored issues of access to care and the degree of financial protection offered to Americans by different insurances. This telephone survey took place before the ACA was implemented, offering a “pre” viewpoint for policymakers to compare the effectiveness of the ACA over time. However, for current policy decisions, the study offers an evaluation of access to health care for people with private insurance, Medicare, Medicaid, or no insurance.

After performing statistical adjustment for factors known to influence access to care, the researchers found significant differences between the uninsured population and all others with coverage. For instance, access to outpatient care was markedly worse for the uninsured relative to private coverage. The uninsured were more likely to have no personal doctor (AOR 3.07) and difficulty accessing a primary care appointment (AOR 2.11) or a specialist appointment (AOR 2.01). While there was trend to poorer specialty access for Medicaid patients as well, there was no statistically significant difference between Medicaid and private coverage for this or other measures of access to outpatient care.

Relative to private coverage, uninsured patients more often used the emergency department as a regular source of care (AOR 4.54) or when another doctor was not available (AOR 2.32).

Similarly, uninsured patients had more financial difficulties compared to private patients. They more often delayed care (AOR 3.79), medications (AOR 2.45). or paying bills (AOR 1.90) due to cost. Patients with Medicare and Medicaid did not differ from private insurance in regards to these financial difficulties. In fact, Medicare and Medicaid patients were less likely to have high out-of-pocket spending compared to private coverage.

In summary, there appears to be no difference in terms of access to care for people with public or private coverage. Therefore, expanding coverage through traditional Medicaid, a Medicaid private option, or a Medicare buy-in can all improve access to care and eventually patient outcomes.

commentary by Cedric Dark

Abstract

OBJECTIVES: To compare access to care and perceived health care quality by insurance type among low-income adults in 3 southern US states, before Medicaid expansion under the Affordable Care Act.

METHODS: We conducted a telephone survey in 2013 of 2765 low-income US citizens, aged 19 to 64 years, in Arkansas, Kentucky, and Texas. We compared 11 measures of access and quality of care for respondents with Medicaid, private insurance, Medicare, and no insurance with adjustment for sociodemographics and health status.

RESULTS: Low-income adults with Medicaid, private insurance, and Medicare reported significantly better health care access and quality than uninsured individuals. Medicaid beneficiaries reported greater difficulty accessing specialists but less risk of high out-of-pocket spending than those with private insurance. For other outcomes, Medicaid and private coverage performed similarly.

CONCLUSIONS: Low-income adults with insurance report significantly greater access and quality of care than uninsured adults, regardless of whether they have private or public insurance. Access to specialty care in Medicaid may require policy attention.

PUBLIC HEALTH IMPLICATIONS: Many states are still considering whether to expand Medicaid under the Affordable Care Act and whether to pursue alternative models for coverage expansion. Our results suggest that access to quality health care will improve under the Affordable Care Act’s coverage expansions, regardless of the type of coverage. PMID: 27196646

Nguyen, KH and Sommers, BD. AJPH.  2016; 106: 1409-15.