Republicans have a handful of go-to criticisms of Medicaid. One is that they believe it costs too much—which is why the House GOP has targeted $880 billion in cuts at the government-run health insurance program for low-income and disabled Americans as part of its Obamacare replacement plan. Of course, simply slashing coverage for the vulnerable seems a bit cold-hearted, so conservatives also like to claim that Medicaid does a poor job serving its beneficiaries, because doctors won't accept it. That makes it easier to say with a straight face that they're interested in “reforming” the program, rather than just bleeding it dry.
You can find variations of this point dating back years. But it's been coming up a whole lot more lately, as Republicans have been trying to sell their austere version of health care reform to a deeply skeptical public. “More and more doctors just don’t take Medicaid,” Paul Ryan told reporters during a PowerPoint presentation a couple weeks back, repeating a claim he'd made in January. “I mean, what good is your coverage if you can’t get a doctor? And that is a huge, growing problem with Medicaid.” When confronted at a CNN town hall by a cancer survivor who'd obtained life-saving medical coverage thanks to Obamacare's Medicaid expansion, Secretary of Health and Human Services Tom Price resorted to a similar argument.
“We have one-third of the physicians in this nation, Brian, who are not seeing Medicaid patients,” Price said (the cancer survivor’s was Brian). “And so if we want to be honest with ourselves as a society, it's important we step back and say, ‘Why is that?’ Why are those doctors not seeing Medicaid patients? Let me just suggest it's because the Medicaid program itself has real problems in it.” Price added that the Trump administration wants to move some patients from Medicaid to private insurance that “might be much more responsive to them.”
It is true that many doctors do not accept new Medicaid patients, in large part because the program pays physicians relatively little for their services. But new data suggests Ryan is dead wrong when he says this is a growing problem. If anything, it appears that more doctors have started to see Medicaid enrollees in the years since the program expanded under the Affordable Care Act. Meanwhile, a recent analysis shows that low-income Americans tend to have similar access to doctors whether they have Medicaid or a private plan, which belies Price's notion that many Medicaid patients would be significantly better off with coverage purchased on the individual market.
In other words, some of the GOP's favorite current talking points about Medicaid are bunk.
When the Washington Post tried to fact-check Ryan's Medicaid claims earlier this year, it had trouble finding any number at all to substantiate them. “I am not aware of any data source that would tell you one way or another whether the number of physicians who accept Medicaid or Medicare, or private insurance for that matter, is going up or down,” Julia Paradise, associate director of the Kaiser Family Foundation’s Program on Medicaid and the Uninsured, told the paper. But a recent survey highlighted by Bruce Jepsen at Forbes suggests the figure has been pretty stable in major metro areas over the past decade. According to the doctor job placement company Merritt Hawkins, 53 percent of physicians in 15 large cities said they were accepting Medicaid patients in 2017. That's up from 45.7 percent in 2014, when the Medicaid expansion began, and down slightly from 2009, when it was 55 percent.
These data may not cover the entire country, but they are instructive. First, they come from a substantial survey. Merritt Hawkins interviewed about 1,400 doctors' offices in large cities like New York, Los Angeles, and Atlanta covering five different specialties: cardiology, dermatology, family medicine, OBGYN, and orthopedic surgery. The company also found that doctors working in midsize metros were slightly more likely to accept Medicaid than their peers in bigger cities, so there's no particular reason to think that Medicaid is facing a more severe crisis outside the country's larger population centers (the report only offered survey results for midsize metros covering 2017). A separate Merritt Hawkins survey of more than 17,000 physicians around the country found that 63.7 percent said they saw all Medicaid patients in 2016, up from 61.9 percent in 2014.*
A pessimist like Price might look at these data and note that, while the problem isn't getting any worse, about half of doctors still aren't taking Medicaid patients or are limiting the number they'll see. That sure makes the program sound dysfunctional. But if you're relatively poor, it turns out that private coverage might not be much better. In November, an analysis by the Medicaid and CHIP Payment Commission showed that Americans who earned less than 138 percent of the poverty line—the population covered under Obamacare's Medicaid expansion—had about the same difficulty getting access to medical care during 2014 whether they had Medicaid or private insurance (that was the first year Obamacare's major pieces were fully implemented). In fact, those with private plans were twice as likely to say they lacked a regular source of medical care, and about 9 percentage points more likely to say they worried about medical bills. Medicaid patients did face slightly longer wait times. But they had far, far better access to medicine than the uninsured. So to demonize Medicaid, as Price does, is to ignore the fact that private insurance faces the same problems, and in some respects more severely.
If you stop and think about it, it makes sense that Medicaid might be about as good, if not better, than cheap private insurance, which tends to be cheap because it's accompanied by high co-pays and deductibles, and keeps costs down by offering patients a narrow network of doctors to choose from. Medicaid, in contrast, “is designed for people who have no money,” University of Chicago professor and health policy expert Harold Pollack told me. “So there are a lot of aspects of Medicaid that are more comprehensive than for people with private coverage.”
The irony about all this is that, whatever Medicaid's deficiencies are now, the Republican plan would almost surely make them worse by cutting the program's budget. Many doctors refuse to take Medicaid patients because the system doesn't pay them enough for their services. As funding shrinks, states will almost surely either have to knock those reimbursement rates lower, cut the enrollment rolls, or perhaps both. It will be become more of a niche, underfunded program, and that will discourage doctors from accepting its patients.
That might not be disastrous for access to care if today's Medicaid enrollees had the prospect of getting better insurance on the individual market, like Price suggested at that CNN town hall. But they don't. Under the Republican health care plan, low-income Americans (and especially low-income, older Americans who are below the qualifying age of Medicare) will receive smaller tax credits to purchase insurance than under Obamacare. Insofar as those families will be able to afford coverage at all, they'll have to opt for something cheaper and less comprehensive than they can get now. It seems plausible those plans will give them even less access to affordable medical care than the Medicaid coverage they enjoy today.
For the Americans who rely on it, Medicaid may not be any less desirable than the private coverage they could theoretically afford in its place. Under the plan Republicans are pushing, both options will simply get worse.
This post has been updated to reflect an additional Merritt Hawkins survey on Medicaid acceptance.