Sunday, July 18, 2010

Re: The UVa Surgical Outcomes Study

Cross-posted from The Agenda on National Review Online.

Austin Frakt thinks I am making too much of the University of Virginia study showing that surgical patients on Medicaid fare more poorly than do the uninsured:
Never draw broad policy conclusions from one study. It could hurt your brain. Well it hurts mine, anyway…The policy implication is that we should make Medicaid as close as possible to private insurance, thereby making Medicaid surgical patients 97% less likely to die. Or, if that is too costly, we should instead make Medicaid more like no insurance at all and boost survival by 13%. Talk about bang for the buck!

One way this could make sense is if very little health care (such as that the uninsured might receive) is bad for you, a little bit of, perhaps low quality, health care (such as that Medicaid patients might receive) is very bad for your health, and a lot of perhaps higher quality health care (that the privately insured enjoy so much) is very very good for you.

Or maybe there’s a problem with the study.
Austin is convinced that access to health insurance is better for health outcomes than being uninsured. That is why he, and many others, supported PPACA. The UVa study agrees with him, insofar as those with private insurance fare much better than do the uninsured.

But what is striking about the study, and what gets to the heart of the policy assumptions around PPACA, is that state-run Medicaid insurance may not make much of a difference. Indeed, the literature as to the poor performance of Medicaid is overwhelming.

Austin’s first criticism—that I am relying on one study—can be addressed by surveying the medical literature for similar studies. The Virginia study appears to be, by far, the largest and most comprehensive surgical outcomes study ever conducted that compares Medicaid to the uninsured. Here are some others:

·    A University of Pennsylvania study published in Cancer found that, in patients undergoing surgery for colon cancer, the mortality rate was 2.8% for Medicaid patients, 2.2% for uninsured patients, and 0.9% for those with private insurance. The rate of surgical complications was highest for Medicaid at 26.7%, as compared to 24.5% for the uninsured and 21.2% for the privately insured.

·    A Columbia-Cornell study in the Journal of Vascular Surgery examined outcomes for vascular disease. Patients with clogged blood vessels in their legs or clogged carotid arteries (the arteries of the neck that feed the brain) fared worse on Medicaid than did the uninsured; Medicaid patients outperformed the uninsured if they had abdominal aortic aneurysms.

·    A study of Florida patients published in the Journal of the National Cancer Institute found that Medicaid patients were 6% more likely to have late-stage prostate cancer at diagnosis (instead of earlier-stage, more treatable disease) than the uninsured; 31% more likely to have late-state breast cancer; and 81% more likely to have late-stage melanoma. Medicaid patients did outperform the uninsured on late-stage colon cancer (11% less likely to have late-stage cancer).

I could keep going, but I don’t want to put our readers to sleep.

I would submit to Austin that, instead of assuming that the study must be flawed, because it jars with his intuition, a more scientific approach would be: what could be the logical explanations for why Medicaid underperforms the uninsured? What does the methodology of the study leave out?

The detailed study results will help us address these questions, but the answer almost certainly begins with access to care. Medicaid’s extreme underpayment of doctors and hospitals leads fewer and fewer health-care providers to offer their services to Medicaid beneficiaries.

This is especially likely to be true at the highest-quality surgical centers. A UCLA study published in the Journal of the American Medical Association found that the uninsured and those with Medicaid were far more likely to be treated in low-volume surgical centers than high-volume ones (high-volume surgical centers have consistently been shown to provide the best outcomes).

Another key element to consider is that many of the uninsured are not poor. According to the Census, 17.5 million of the uninsured make more than $50,000 a year. (Median U.S. income is around $40,000 per year.) These individuals are wealthy and/or healthy enough that they have decided to forego insurance. Though the Virginia study corrects for income status and other social factors, the fact that these patients are more capable of paying directly for their own care, at the prevailing rate, means that physicians are more willing to see them.

There is, doubtless, a level of poverty at which Medcaid is better than nothing at all. But most people can afford to take on more responsibility for their own care, and indeed would be far better off doing so.


  1. Someone once said poor people are poor people. As a group, the uninsured are usually a lot nicer to work with than the Medicaid population. They also follow directions better and communicate better. At least that is my inpatient experience. If you are running a food cart and decide to forego insurance because of costs, you are probably a much more functional person than someone who has been on Medicaid for a few years. Not all of course, but certainly a lot.


  2. Hi Steve, I think you've hit on something that gets short shrift in all of this: the corrosive effects of welfare dependency.