Medicaid

I’ve always told my health economics students that Medicaid is both better and worse than all other insurance in the US for its enrollees.

Better, because its cost sharing is dramatically lower than typical private or Medicare plans. For instance, the maximum deductible for a Medicaid plan is $2.65. Not $2650 like you might see in a typical private plan, but two dollars and sixty five cents; and that is the maximum, many states simply set the deductible and copays to zero. Medicaid premiums are also typically set to zero. Medicaid is primarily taxpayer-financed insurance for those with low incomes, so it makes sense that it doesn’t charge its enrollees much.

But Medicaid is the worst insurance for finding care, because many providers don’t accept it. One recent survey of physicians found that 74% accept Medicaid, compared to 88% accepting Medicare and 96% accepting private insurance. I always thought these low acceptance rates were due to the low prices that Medicaid pays to providers. These low reimbursement rates are indeed part of the problem, but a new paper in the Quarterly Journal of Economics, “A Denial a Day Keeps the Doctor Away”, shows that Medicaid is also just hard to work with:

24% of Medicaid claims have payment denied for at least one service on doctors’ initial claim submission. Denials are much less frequent for Medicare (6.7%) and commercial insurance (4.1%)

Identifying off of physician movers and practices that span state boundaries, we find that physicians respond to billing problems by refusing to accept Medicaid patients in states with more severe billing hurdles. These hurdles are quantitatively just as important as payment rates for explaining variation in physicians’ willingness to treat Medicaid patients.

Of course, Medicaid is probably doing this for a reason- trying to save money (they are also trying to prevent fraud, but I have no reason to expect fraud attempts are any more common in Medicaid than other insurance, so I don’t think this can explain the 4-6x higher denial rate). This certainly wouldn’t be the only case where states tried to save money on Medicaid by introducing crazy rules hassling providers. You can of course argue that the state should simply spend more to benefit patients and providers, or spend less to benefit taxpayers. But the honest way to spend less is to officially cut provider payment rates or patient eligibility, rather than refusing to pay providers as advertised. In addition to being less honest, these administrative hassles also appear to be less efficient as a way to save money, probably because they cost providers time and annoyance as well as money:

We find that decreasing prices by 10%, while simultaneously reducing the denial probability by 20%, could hold Medicaid acceptance constant while saving an average of 10 per visit.

Medicaid is a joint state-federal program with enormous differences across states, and administrative hassle is no exception. For administrative hassle of providers, the worst states include Texas, Illinois, Pennsylvania, Georgia, North Dakota, and Wyoming:

Source: Figure 5 of A Denial a Day Keeps the Doctor Away, which notes: “The left column shows the mean estimated costs of incomplete payments (CIP) by state and payer. The right column shows the mean CIP as a share of visit value by state and payer. “

Medicaid is a health insurance program for those with low incomes, funded largely by states. Overall it accounts for less than 20% of US medical spending. But there is one area where it is the dominant payer: nursing homes. Nursing homes are expensive, and Medicare (the typical insurance for those over 65) won’t cover them after the first hundred days, so most nursing home residents end up paying out of pocket until they burn through all their savings and wind up on Medicaid. At which point, Medicaid pays about $100,000 per year to the nursing home for the rest of their life.

States are responsible for up to half of that cost, and so start looking for ways to save money. One idea they have is to make it harder to build nursing homes: if there aren’t beds available, potential nursing home patients will have to stay home instead, where they can’t rack up Medicaid spending the same way. In fact, some states go all the way to a complete moratorium on new nursing homes:

Some other states allow new nursing homes, but only with a special permission slip called a Certificate of Need (CON). CON is often required for other types of health facilities as well, like hospitals or dialysis centers. Research by me and others has generally found that CON doesn’t work as a way to reduce spending, and in fact actually increases it. CON might reduce the number of facilities, but that reduction of supply and competition gives the remaining facilities more power to raise prices.

So which effect dominates- does the smaller number of facilities reduce total spending, or do the higher prices increase it? It depends on the elasticity of demand:

In health care demand is typically quite inelastic, so the price effect dominates, and spending goes up:

But nursing homes could be an exception here. Elasticity of demand could be relatively high because of the number of potential substitutes- home care or assisted living for those with relatively low medical needs, hospitals for those with relatively high medical needs. Plus this is the one type of health care where Medicaid is the dominant payer. They could be especially resistant to price increases here, both due to their market power and their willingness to keep prices so low that facilities won’t take Medicaid patients (another way to save money!).

A new paper by Vitor Melo and Elijah Neilson finds that this is indeed the case. Indiana, Pennsylvania, and North Dakota repealed their nursing home CON requirements in the ’90s, and at least for IN and PA their Medicaid spending went way up. The paper uses a new “synthetic difference in difference” technique that seems appropriate, and creates figures that seem confusing at first but get a ton of information across:

They correctly note that they don’t evaluate the welfare effects of the policy; it’s possible that the extra nursing home beds following CON repeal bring huge benefits to seniors that are worth the higher spending. But nursing homes could be the exception to the general rule that CON fails to achieve the goals, like reduced spending, that advocates set for it.