The Intolerable Side Effect of Access to Care

Debates around health reform are often viewed through a political lens. Assessing the outcome of the ACA is no different. If the central goal of health reform is to increase access to care, there can be little debate as to whether expanding programs such as Medicaid would be successful. However, secondary goals associated with expanding access to health care, such as cost-effective provision of medical care, exist in a gray-zone where assumptions, political biases, and the social lens through which we view health care have undue influence.

In a study of the effects of Medicaid expansion, researchers looked at access to dental care in Oregon. The Oregon legislature awarded Medicaid spots via a lottery system that allowed researchers to develop a prospective randomized study.

Results showed that those who were previously uninsured and were awarded Medicaid demonstrated improved access to dental care. Researchers found improvements in perceptions of health, increases in health care utilization and expenditures, and a reduction in the number of individuals requiring dental services. Researchers also discovered that out-of-pocket expenditures increased, despite often repeated statements that improved insurance coverage would lead to lower patient costs.

In medicine, no intervention comes without a cost, whether in the form of financial burden or physiologic side effects. Health reform also carries societal and economic costs along with benefits. Although increasing access to health care is a laudable goal, studies of the ACA have largely reflected an increase in utilization and costs, though these studies have only reflected short-term outcomes. This may be surprising to many single-payer or universal health care advocates but the findings make sense. Short term costs will likely rise as more people follow-up on previously ignored acute care needs or pursue additional preventative measures. Long-term financial benefits may not be seen for years.

Fiscal conservatives point to these increased expenditures as an intolerable side effect, often support limiting access to care as a strategy to limit health care costs. This viewpoint does ignores that access to reasonable acute and chronic care is a service other industrialized nations have provided to their citizens often with better outcomes and at lower costs than in the United States. The ACA’s Medicaid expansion represents an incremental improvement that meets our country’s economic and social needs as well as the individual health needs of our citizens.

commentary by Orlando Sola, MD and Robert Wang, MD. Dr. Wang is a PGY-2 at the SUNY Downstate Family Medicine residency program.

Abstract

OBJECTIVE: To evaluate the effect of Medicaid coverage on dental care outcomes, a major health concern for low-income populations.

DATA SOURCES: Primary and secondary data on health care use and outcomes for participants in Oregon’s 2008 Medicaid lottery.

STUDY DESIGN: We used the lottery’s random selection to gauge the causal effects of Medicaid on dental care needs, medication, and emergency department visits for dental care.

DATA COLLECTION: Data were collected for lottery participants over 2 years, including mail surveys (N = 23,777) and in-person questionnaires (N = 12,229). Emergency department (ED) records were matched to lottery participants in Portland (N = 24,646).

PRINCIPAL FINDINGS: Medicaid coverage significantly reduced the share of respondents who reported needing dental care (-9.8 percentage points, p < .001) or having unmet dental care needs (-13.5 percentage points, p < 0.001). Medicaid doubled the share visiting the ED for dental care (+2.6 percentage points, p = .003) and the use of anti-infective medications often prescribed for dental care, but it had no detectable effect on uncovered dental care or out-of-pocket spending.

CONCLUSIONS: Expansion of Medicaid covering emergency dental care substantially reduced unmet need for dental care, increasing ED dental visits and medication use, while not changing patient use of uncovered dental services.

PMID: 28884818

Baicker, K, et al. Health Serv Res. 2017 Sep 8. Epub