Building the Case for Medicaid Reform

Cross-posted from The Agenda on National Review Online.

For those who haven’t had their fill of the Medicaid reform discussion, the full results of the UVa surgical outcomes study have been published in the online edition of Annals of Surgery. (I ask everyone who has had their fill for forgiveness.) There are a couple of points that keep coming up in the comments and in responses from other bloggers, so I want to spend at least one post addressing them.

Austin Frakt writes that, contrary to my expressions of concern, he is quite open-minded to the possibility that outcomes with Medicaid are poorer than those of the uninsured (and especially those with private insurance). He remains reasonably skeptical that studies like the Virginia one adequately control for the poor social and health status of the Medicaid population:

There are undoubtedly studies that consider Medicaid vs. uninsured outcomes using the random variations provided by the natural experiment that is Medicaid. Characteristics of the program vary by state and year, making it a perfect set-up for such an analysis of this issue. This second I can’t point to a study. But I know where to look. One place to start would be to examine the literature cited by Stan Dorn on Ezra Klein’s blog at the Washington Post (tinyurl.com/StanDorn), Harold Pollack on The New Republic’s The Treatment blog (tinyurl.com/HPollack), and by J. Michael McWilliams on this blog (tinyurl.com/JMMcWill).

That’s it. That’s my position, and it always has been. If you read carefully you ought to notice that I didn’t actually condemn or praise Medicaid. I didn’t actually say how it should be reformed. I just listed the possibilities.

It is certainly important, in any study comparing Medicaid to other insurance populations, to control for the kinds of things, like prior health status, that negatively skew Medicaid outcomes. In medicine-speak, these factors are called comorbidities. As I have written before, one must be careful with comorbidity analyses not to eliminate the ways in which Medicaid actually contributes to poor health status.

Having said that, the authors of the Virginia study did control for 30 different comorbidity measures, using a widely used, highly validated methodology first worked out by Anne Elixhauser and colleagues in 1998. Using 1992 data from 438 California hospitals, Elixhauser et al. identified those factors that most significantly contributed to “substantial increases in length of [hospital] stay, hospital charges, and mortality.”

Notably, the Elixhauser comorbidities include several factors that many associate with the Medicaid population: AIDS, alcohol abuse, depression, drug abuse, liver disease (such as hepatitis), obesity, and psychoses.

(The others are: deficiency anemia, arthritis/collagen vascular disorder, chronic blood loss anemia, congestive heart failure, chronic pulmonary disease, coagulopathy, uncomplicated and complicated diabetes, high blood pressure, hypothyroidism, lymphoma, fluid and electrolyte disorder, malignant cancer, neurologic disorders (other than stroke), paralysis, peripheral vascular disease, pulmonary circulation disorder, renal failure, solid tumors (non-malignant), peptic ulcer disease (without bleeding), heart valve disease, and weight loss.)

The Virginia study authors also controlled for income, age, and gender.

To me, this is a responsible, comprehensive, and quantitatively validated list of comorbidities and adjustments. To those who disagree: what other adjustments would you have preferred to see? Which, if any, of these additional adjustments would have had a significant impact on the results of the study? What data can you cite to support their importance, and to support that they are independent of the effects of Medicaid itself or of welfare dependency? Austin has written extensively about the general concept of controlling for extenuating factors, so his thoughts on this topic could be illuminating.

Austin also writes that a definitive study to measure the benefits of Medicaid against those with other forms of insurance (or uninsurance) would need to be prospective—that is to say, we take X number of people, put half on Medicaid and half on something else, and see what happens. While he’s right that prospective studies are, all else being equal, better than retrospective ones, they can also be misleading if they aren’t stratified properly by health status, social factors, etc. Another disadvantage of prospective studies is that they usually sample a much smaller number of people than retrospective studies can. Even if we could design a good prospective Medicaid study, actually conducting one would be very difficult and take several decades to play out. I hope we can all agree to use the best available evidence in the meantime.

I would also point out to Austin that exactly the same arguments could be applied to PPACA: i.e., let’s do some well-designed, prospectively-controlled studies before adding 16 million people to the Medicaid rolls at a cost of $100 billion a year.

Aaron Carroll points out that the UVa study focuses solely on surgical outcomes. Aaron, as a pediatrician, wonders whether its results are applicable to non-surgical situations. I have addressed this issue in part, but I will take a look at pediatric outcomes in a separate post.

Aaron also notes that Medicaid is voluntary: but this is weak support for the implication that Medicaid, in its current form, is the best we can do. In the Vietnam days, some conservatives used to tell liberals to “love [America] or leave it.” I don’t remember liberals being too happy about that. Nor does Medicaid’s voluntary nature mean, ipso facto, that it must be doing some good. Does the voluntary nature of Medicare overutilization mean that Medicare overutilization is a good thing? Most liberal health policy types that I know believe otherwise.

A number of people ask: “Ok, let’s suppose for a minute that the UVa study is accurate, and that those on Medicaid do fare worse than the uninsured. Are you suggesting that we abolish Medicaid and do nothing about the problem of the uninsured?” No—I am suggesting that we transition to something akin to the Swiss model, whereby we offer graduated subsidies with which the poor can buy consumer-driven private insurance. Simply sending them the cash would be far more efficient than what we do now.

I would ask those who ask these philosophical questions if they are happy with Medicaid as it is, or if they have their own ideas for reform. Hopefully we can get past this idea that criticizing Medicaid equals seeking to abolish assistance for the needy.

The evidence of Medicaid’s problems is, in my view, overwhelming. I encourage those who believe otherwise, or are simply agnostic, to spend some time going through the data. Medicaid reform is an issue that should unite those who are concerned with the plight of the poor, and those who are concerned about America’s fiscal condition. These are the two things, after all, that health care reform was supposed to be about.

Medicaid Reform in One Easy Step

Cross-posted from Critical Condition on National Review Online.

Stimulated by the comments of reader Joe C., I went back and looked at the Medicaid numbers. From 2010-2017, here are the Congressional Budget Office’s pre-Obamacare projections for the number of people covered by Medicaid and CHIP, and the Medicaid Actuary’s 2008 projections for federal and state spending on Medicaid (apologies for the small type):

Year (pre-PPACA)	2010	2011	2012	2013	2014	2015	2016	2017
Covered lives (millions)	40	39	39	38	35	34	35	35
Federal expenditures ($bn)	$392.6	$424.0	$457.4	$494.0	$533.3	$576.4	$623.0	$673.7
Federal share	$223.5	$241.3	$260.3	$281.1	$303.5	$328.0	$354.5	$383.4
State share	$169.1	$182.7	$197.1	$212.9	$229.8	$248.4	$268.5	$290.3
Cost per covered life	$9,815	$10,872	$11,728	$13,000	$15,237	$16,953	$17,800	$19,249
Growth rate		10.8%	7.9%	10.8%	17.2%	11.3%	5.0%	8.1%

As you can see, we currently spend almost $10,000 per Medicaid beneficiary, a number that will exceed $19,000 in 2017. The growth of per-beneficiary expenditures is not only well above conventional inflation, but also health care inflation. This is why Medicaid is annihilating state budgets.

What does the average individual health plan cost in the private sector, you ask? According to the Commonwealth Fund, the average private-sector individual health plan in 2008 cost $4,386. If we assume that premiums increased by 6% in 2009 and 2010, we get to a 2010 average of $4,928. In other words, the government is spending twice per Medicaid enrollee than middle-class Americans spend on their own insurance. And this is the system that PPACA wants to expand by nearly 50%.

Austin Frakt asks us to choose between two options: being uninsured, or accepting Medicaid. He posits that most people given that choice would accept Medicaid, despite its problems, and so the solution is to spend more money on the program. But this is a false choice, for two reasons.

The first is, as I’ve discussed elsewhere, a large proportion of the uninsured are not poor. These people are uninsured by choice. (In Massachusetts, instead of responding to the individual mandate, as Austin and others suggest they have, such people will game the system by claiming they have insurance when they don’t.) There are definite advantages to being uninsured over being on Medicaid, if you can pay the bills. The most significant of these is that nearly any doctor will take an appointment with someone who is willing to pay out-of-pocket.

The second of these, and the most important, is: why on earth are we spending twice as much on people with Medicaid as we do on private insurance for middle-class Americans, only to get substantially worse medical outcomes? People on Medicaid have poorer access to care (for reasons I have discussed elsewhere), and have more health problems in general. Let’s generously say that their health care should cost 50% more than that of the average American.

So here’s a modest proposal: Instead of spending $400 billion on Medicaid in 2010, let’s spend $300 billion, but instead of spending it on Medicaid, or even on vouchers, let’s write checks to the poor. Instead of filtering $9,815 per Medicaid enrollee through a cascade of government employees, let’s send $7,361 in cash into the mailboxes of impoverished individuals, to spend on whatever is most important to them and their families. It achieves more efficient wealth redistribution than does Medicaid, and allows the poor to afford high-quality, private-sector health insurance. If they are healthy, they can buy inexpensive insurance and save the extra cash; if they are sick, they can use the entire amount for insurance. This approach would not only save money, and appeal to the poor, but it would align Medicaid inflation with health inflation, saving trillions of dollars over time. Indeed, if healthy Medicaid beneficiaries choose less-expensive, consumer-driven plans, such a reform could actually bring Medicaid inflation below overall health inflation.

I can already hear an objection: what if they spend the cash on bad things, like alcohol, instead of good things, like health insurance? I would argue that the enormous efficiencies of a direct transfer payment outweigh that risk. At any rate, vouchers are designed to address exactly that concern. But those who wish to better control how the poor spend taxpayers’ money are perfectly able to do so without my encouragement.

Re (3): UVa's Surgical Outcomes Study

Cross-posted from The Agenda on National Review Online.

Austin Frakt is back for more, with two more posts on the issue of Medicaid’s poor performance in outcome studies vs. the uninsured. I am afraid that Austin makes a couple of analytical errors. These will take some time to go through, so I forgive readers who don’t want to wade in the tall weeds with me. In summary, the evidence Austin cites to argue that Medicaid might be just fine actually demonstrates the opposite: that Medicaid patients get worse medical care than do the uninsured, and that PPACA’s massive expansion of Medicaid will have tragic consequences.

To begin with, Austin is re-energized by some useful commentary from Aaron Carroll. Writes Carroll:

- Insurance doesn’t equal care.  Insurance can affect how likely you are to get care and how quickly you might get it.  But any study that looks at insurance has to adjust for many, many other variables in order to get the true effect of insurance.

- There is a large body of literature out there on insurance.  A lot of it shows that people with private insurance do better than those with public insurance or those without insurance; that should not be a surprise.  Most people (and most of your docs) would rather have private insurance than Medicaid.  But would you really rather have no insurance than Medicaid?  If so, that is everyone’s right.  Don’t get the Medicaid.  I wager few would make that choice.

- I find it interesting that most of the literature that Avik cites is about surgery.  Surgery is different than other types of care (like emergency care) in that it is harder to refuse.  So it may be that the uninsured are getting care on a compassionate basis.  Few would provide a screening mammogram or yearly colonoscopy to someone uninsured, however, and you would get that with Medicaid.

I entirely agree that insurance does not equal care: indeed, this is the point I have been trying to make all along. Medicaid, in particular, because it is heavily underfunded and mismanaged, is insurance of a kind, but not care. And as I pointed out in my previous post, arguments that the studies don’t adjust for enough variables miss the point. We are trying to distinguish between cause and effect: what elements of Medicaid’s poor outcomes are caused by Medicaid, and what elements are inherent to the Medicaid population? Clearly, things like one’s race or gender or age are not caused by Medicaid. But the chronically poor care that Medicaid patients receive, because they have poor access to physicians, is directly responsible for many of their comorbidities. Therefore, correcting for comorbidities, while a useful tool, treats Medicaid overly generously.

Medicaid, due to its extreme underpayment and other problems, gives its beneficiaries very poor access to health care—things like annual checkups, screenings, etc. In Texas, for example, only 32 percent of all physicians are willing to see Medicaid patients. A nationwide survey of major metropolitan areas found that 55% of physicians accepted Medicaid, with particularly low numbers for specialists.

Skeptics of the Virginia study want us to say: “The studies are flawed! They don’t consider all of subtle ways in which Medicaid patients are worse off!” Well, what if the main reasons that Medicaid patients are worse off has something to do with…Medicaid?

As to Carroll’s point about the fact that the uninsured aren’t getting mammograms and colonoscopies, but Medicaid patients are: that isn’t true, because Medicaid patients can’t get appointments to see doctors (see above). If Carroll was right, it would only render even more striking the fact that the uninsured have their cancers detected earlier than do Medicaid patients. With breast cancer specifically (since he brings up mammograms), Medicaid patients were 31% more likely to have late-stage breast cancer than the uninsured. With surgical resections for colon cancer (since he brings up colonoscopies), in a separate study, Medicaid patients had a 27% higher risk of mortality than the uninsured, and a 9% higher risk of surgical complications.

Carroll makes another minor point, which Frakt echoes:

I’m going to take a tiny issue with Avik’s first post.  It was based on (as far as I can tell) a meeting abstract…I’m not saying the results of Avik’s discussed study aren’t valid.  I’m saying I can’t tell.  And neither can you, without more information.  The peer review for a meeting just isn’t the same as for full publication.  You have less time, different criteria, and almost nothing by which to judge the work.

As I have commented elsewhere, the full study is in press in the Annals of Surgery. It should be out in a few weeks, relieving Carroll's concerns. I certainly agree that the detailed study results, published in a peer-reviewed journal, will be useful. Skeptics of the study are setting themselves up for disappointment if they hope that the detailed results will exonerate Medicaid. Indeed, the detailed results are likely to show that social factors (e.g. alcohol and drug abuse) were counted as comorbidities, and were not meaningfully different between Medicaid and the uninsured anyway.

The Virginia study is based on the largest publicly available inpatient database in the U.S., that of the Nationwide Inpatient Sample. The NIS represents approximately 20% of all hospital discharges in the country. The UVa study is the most comprehensive analysis, with the largest sample size, of any published study comparing surgical outcomes on the basis of insurance status.

So, back to Austin Frakt. Austin implies that the Virginia study, and the other studies I cite, are “cherry-picked.” I can assure him that the four studies I described are representative. He is more than welcome to slog through the medical literature, as I did, and see if he comes up with a different conclusion. He won’t.

Austin then goes and picks out a single study, the thing he had earlier criticized me for, and uses that study to suggest that it is premature to conclude that Medicaid patients fare worse than the uninsured. Even worse, Austin actually misinterprets the results of the study he cites! Let us quote its authors (emphasis mine):

Most of the reasons for insurance-related disparities noted above for the uninsured are also applicable to Medicaid patients. Differences in the intensity of inpatient care, limited access to health care services, unmet health needs, and suboptimal management of chronic medical conditions were also reported for Medicaid patients in prior research. These factors likely contributed to the higher in-hospital mortality in this patient population, evidenced by the sequential decrease in odds after adjusting for comorbidities and disease severity.

Translation: Medicaid patients have poorer access to physicians. As a result, their diseases are managed very poorly. This leads them to die in the hospital at higher rates than the uninsured (in Austin’s study, Medicaid patients had a higher mortality than the uninsured with heart attacks and pneumonia, but did better than the uninsured with strokes). As the authors note, additional adjustments for risk factors increase the evidence that Medicaid is the problem, because those risk factors are the ones that Medicaid exacerbates.

I am glad that Austin has taken on this challenging subject. But I encourage him to take the effort he spends attempting to dispute that Medicaid has problems with access to care and medical outcomes, and apply it to actually solving those problems. (Suggesting that we throw an extra $200 billion a year into Medicaid is not viable.) I hope I am wrong, but I fear that he is less than enthusiastic about addressing the problems, because that would require him to acknowledge that PPACA’s massive expansion of Medicaid was a catastrophic mistake.

Re (2): The UVa Surgical Outcomes Study

Cross-posted from The Agenda on National Review Online.

I’m grateful for Austin Frakt’s continued interest in the problem of Medicaid’s poor outcomes. Here are his most recent thoughts:

Avik Roy responds to my post. He lists several more studies that find Medicaid patients have far worse outcomes than privately insured ones and the uninsured too. I’m not going to undertake a literature review. I don’t have time. So, I’m not really debating the merits of the studies Avik Roy cites or whether they are representative of the entire body of work in this area.

So, let’s presume they are credible and representative, then what is the implication? Should we make Medicaid more like private insurance or more like no insurance? Should we Federalize the program?

I believe that everyone should have access to affordable insurance that facilitates access to affordable, high-quality care…If Medicaid doesn’t fill that role for low-income individuals, some of whom are very sick and/or disabled, then it should be reformed. That probably means spending more money on it.

I’m not getting the sense that’s what Roy has in mind. He writes that “most people can afford to take on more responsibility for their own care, and indeed would be far better off doing so.” That sounds like he wants to make Medicaid more like no insurance.

Austin is a thoughtful guy, so I’m surprised to see him argue that throwing more money at a dysfunctional system is the best path forward. We already spend $436 billion a year on Medicaid, only to achieve the dismal results reflected in the Virginia study. Once PPACA is fully implemented, Medicaid may surpass Medicare as our most expensive health-care program. Medicaid is overwhelming state budgets, crowding out other essential government services. And I haven’t even mentioned our federal deficit. In the post-Obamacare era, increasing physician reimbursement for Medicaid patients to still-stingy Medicare levels will cost $200 billion a year. If Austin has that kind of change under his couch, he should let us know!

I instead favor, as a start, what Mitch Daniels has accomplished with the Medicaid program in Indiana (before PPACA destroys it): subsidized health savings accounts combined with consumer-driven health plans. And Indiana covers people at up to 200% of the poverty line, compared to Obamacare’s 133%. Instead of covering more people, I would more heavily subsidize those at or below the poverty line, in order to bring Medicaid’s low physician payments in line with those of the private sector. Ideally, we would move to a modified version of the Swiss model, in which everyone purchases consumer-driven plans in the individual market, with graduated subsidies for lower-income households.

Ultimately, the goal should be to minimize the number of people who require subsidized insurance. This requires comprehensive health reform aimed at reducing the cost of health care: de-linking employment from insurance; broadening the reach of consumer-driven care; creating a national insurance market; aggressive antitrust enforcement against providers; medical tourism; transparency; malpractice reform; and Medicare reform.

Austin also passes along the comments of some of his readers, who question the methodology of the Virginia study. Reader Jay worries that the Virginians didn’t control for prior health status. On the contrary, they controlled for 30 co-morbid conditions, along with age, gender, income, geographic region, and surgical procedure. They may not have directly controlled for smoking or alcohol consumption (we don’t yet know), but these issues would show up in the comorbidities and in the surgeries themselves. For example, lung resections are typically performed on smokers.

Reader Steve worries that they chose procedures that would be heavily tilted to academic centers, and that this biases the results. From my reading, the procedures they chose are among the most common high-morbidity surgical procedures performed today, which is what you would want an outcomes study to examine. A larger issue, which I discussed in my previous post, is that Medicaid patients appear to spend more time in low-volume surgical centers.

Steve also says:

I would bet almost anything that they do not look at all of the social factors that would contribute to worse outcomes for a Medicaid population. Docs don’t generally look for those. If you are uninsured, how long have you been uninsured? Are you working if you are uninsured? What is the functional capability of someone on Medicaid not working vs. someone uninsured who is working? Which group is more likely to have communication problems? Which group is more likely to give a better history? Which group is more likely to get family support? Which group is staff more likely to dislike?

Steve is missing the point. It’s not the job of these studies to eliminate every conceivable factor that leads Medicaid patients to underperform the uninsured. Rather, they are seeking to establish whether or not Medicaid patients underperform the uninsured, after controlling for basic factors like age, income, and comorbidities. Once you establish that Medicaid underperforms, you can then begin to propose hypotheses as to why this underperformance happens.

On this score, Steve has reversed the cause and the effect. Welfare dependency is what leads to problems like family breakdown, underemployment, and diminished functional capabilities. Dumping 16 million more Americans into our broken Medicaid system is not the answer, but rather its antonym. It is not compassionate, but cruel.

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.

UVa Study: Surgical Patients On Medicaid Are 13% More Likely To Die Than Those Without Insurance

Cross-posted from Critical Condition on National Review Online.

At a cost of nearly $100 billion a year, Obamacare adds 16 million people to the rolls of Medicaid. The President and his allies are most proud of this aspect of the new law, as it helps to fulfill a long-held progressive goal of providing government-funded health insurance to all Americans.

Except that Medicaid is broken. Medicaid so severely underpays doctors—reimbursing them at 72 percent of already-stingy Medicare rates—that many physicians refuse to see Medicaid patients. Medicaid patients, in turn, fill up emergency rooms, where they delay the care of the seriously injured.

Now comes word, via a large study by the University of Virginia (h/t Joseph Colletti), that surgical patients on Medicaid are 13% more likely to die than those with no insurance at all, and 97% more likely to die than those with private insurance.

The Virginia group evaluated 893,658 major surgical operations from the Nationwide Inpatient Sample database from 2003 to 2007. They divided the patients up by the type of insurance—private insurance, Medicare, Medicaid, and uninsured—and adjusted the database in order to control for age, gender, income, geographic region, operation, and comorbid conditions (having 2 or more diseases simultaneously). That way, they could correct for the obvious differences in the patient populations (for example, older and poorer patients being more likely to have ill health).

They then examined three measurements of surgical outcome quality: the rate of in-hospital mortality; average length of stay in the hospital (longer stays in the hospital are a marker of poorer outcomes); and total costs.

Outcome	Private	Medicare	Uninsured	Medcaid
In-Hospital Mortality (vs. Private Insurance)	1.00	1.54	1.74	1.97
Length of Stay (days)	7.38	8.77	7.01	10.49
Total Costs ($)	$63,057	$69,408	$65,667	$79,140

The in-hospital death rate for surgical patients with private insurance was 1.3%. Medicare, uninsured, and Medicaid patients were 54%, 74%, and 97% more likely to die than those with private insurance.

The average length of stay in the hospital was 7.38 days for those with private insurance; on an adjusted basis, those with Medicare stayed 19% longer; the uninsured stayed 5% shorter; and those with Medicaid stayed 42% longer.

Total costs per patient were $63,057 for private insurance; Medicare patients cost 10% more; uninsured patients 4% more; and Medicaid patients 26% more.

In summary: Medicaid patients were almost twice as likely to die as those with private insurance; their hospital stays were 42% longer, and cost 26% more. Compared to those without health insurance, Medicaid patients were 13% more likely to die, stayed in the hospital for 50% longer, and cost 20% more. It is hard to see how this problem doesn’t get significantly worse when Obamacare’s expansion of Medicaid is fully phased in.

Remember these statistics the next time you see a study claiming that the quality of American health care is no better than that of Europe. Such studies rarely separate patients with Medicaid and Medicare from those with private insurance.

The Virginia study reminds us that the true cost of government health care is not its impact on the budget, but its impact on the lives and health of every American. We can only hope that our representatives in Washington begin to understand this.