Medicaid patients receive unequal treatment.

• Author: Norman, Robert A.

In September, 1990, The Journal of the American Medical Associaton (JAMA) published an article analyzing the care received by 37,944 patients with Medicaid, private health insurance, or no insurance at all who had been admitted to various Massachusetts hospitals with chest pains or circulatory problems. It reported that privately insured patients received more care. For example, they had an 80% greater chance of receiving an angiography (a test for blocked arteries) than did those without insurance. Privately insured patients also were 40% more likely to get expensive coronary bypass surgery and 28% more likely to undergo angioplasty to clear arteries with a ballon-tipped catheter.

A JAMA article by Chris Hafner-Eaton in February, 1993, further detailed the disparities of physician utilization between the uninsured and insured. He compared chronically ill, acutely ill, and well nonelderly populations and noted large inequities in utilization of care by the uninsured, particularly for chronically ill and well individuals.

Study after study has shown that disadvantaged patients are at high risk for delayed care. Many of the conditions they seek help for eventually end in hospitalization. The delays are associated with worse outcomes, longer hospital stays, and, consequently, greater costs.

Medicaid programs throughout the nation traditionally have offered their clients coverage via a fee-for-service system, reimbursing health care providers for each service provided to an eligible Medicaid client. The fee-for-service model deals primarily with claims payment and offers only a sprinkling of care coordination and management. As such, it is hit-or-miss medicine with few ongoing relationships and initial need for care often being of an acute nature. Consequently, what has evolved are highly ineffective, expensive patterns of care. Medicaid patients frequently use emergency rooms as primary care sites. Meanwhile, health care costs have more than doubled, from 51,600,000,000 in 1988 to 120,000;. 000,000 in 1992.

Many states have been hit heavily by Medicaid cutbacks. Pennsylvania for example, is projecting a $63,600,000 loss in Federal assistance. The drop, due to a rise in per-capita income, would be the largest of any state. Pennsylvania already is running a $40,000,000 deficit and expected to lose almost 350,000,000 when a hospital financing agreement expired at the end of 1993. Other states that will suffer large Medicaid losses are Washington...