Coverage, access, and outcomes: Oregon’s Medicaid experiments

While we take a breather during this holiday season, we’re re-posting content from earlier in the year. This post was originally published on January 6, 2014.

by Liz Borkowski, MPH

Now that it’s 2014, millions more people in the US have health insurance coverage (either Medicaid or private insurance), thanks to the Affordable Care Act. In the weeks ahead, many of the newly insured will be visiting healthcare providers to address ongoing health concerns. The Washington Post’s Sandhya Somashekhar and Karen Tumulty highlighted one person with a pent-up demand for healthcare, Sharon Kelly of Louisville, Kentucky:

Kelly said that having Medicaid coverage on Jan. 1 “is a huge relief,” adding, “I’m a redhead and I used to live in California. I have things on my skin that are probably cancer. I just sit here watching these things change color, waiting for January 1st, so I can get an appointment with a dermatologist.”

As the newly insured try to schedule appointments and address ongoing health problems, we’ll start getting answers to two important questions: Will health insurance translate into access to healthcare? And will those gaining coverage enjoy better health?

Having an insurance card doesn’t necessarily mean you’ll be able to get an appointment to see your doctor when you need to. Some parts of the country don’t have enough healthcare providers to deliver the recommended primary or secondary care to all residents. In some cases, providers have appointment slots available, but patients can’t get the time off work or the transportation to visit those providers. Others could make it in for an appointment but can’t afford the co-payment or deductible they’d need to pay in order to be seen. Language barriers and facilities inaccessible to those with disabilities can also complicate access to healthcare.

And whether or not an insured person can see a doctor, insurance and healthcare services don’t automatically equal better health outcomes. For instance, a diabetic patient might have health insurance and visit a healthcare provider regularly, but still find it difficult to monitor his blood sugar, take his medications, and follow diet and exercise guidelines. (Community characteristics like the availability of safe places to exercise can influence exercise patterns, and researchers have documented the physical, psychosocial, and workplace factors that make it challenging for many low-wage workers to eat healthily and get recommended exercise.)

As states are deciding whether to expand their Medicaid programs under the Affordable Care Act, two experiments in Oregon are helping to answer questions about the healthcare and health outcomes of previously uninsured individuals who gain Medicaid coverage.

A limited expansion and a new Medicaid model
Years before the ACA was passed, Oregon determined that it could offer Medicaid coverage to a limited number of low-income adults. The state couldn’t afford to provide coverage to all who wanted it, so in 2008, it used a lottery to determine who would get the coverage. That created the conditions for a randomized trial to evaluate the effects of extending Medicaid to the previously uninsured. The Oregon Health Study group has been following a group of Oregon adults and comparing the experiences of those who received new Medicaid coverage to those who did not.

The group’s latest study, just published in Science, used data from 2007 and 2009 (one year before and one year after the expansion), and focused on Portland-area hospitals. The researchers, Taubman et al, found that those who gained Medicaid coverage significantly increased their emergency-department use, compared to those who did not gain coverage.

That’s not an encouraging result, but there’s better news from more recent activities. Since the limited 2008 Medicaid expansion took place, Oregon has launched a prevention-focused effort to improve health while slowing the growth of healthcare costs. The plan involves major changes to the state’s Medicaid program starting in 2011, including offering patient-centered primary care to Medicaid recipients. As Wonkblog’s Sarah Kliff explained last year, the state hopes that by better coordinating healthcare and other assistance, they can prevent the kinds of costly complications that land patients in hospitals and nursing homes. (This is especially important because Oregon has accepted the ACA’s Medicaid expansion and is seeing enrollment grow.) Kliff gave an example of what such coordinated care can look like:

At the Mosaic Medical clinic in Prineville, a tiny Central Oregon logging town of 9,192, Juana Martinez and Michelle Ortiz are practicing the type of medicine that [Governor John] Kitzhaber thinks could fix the system. They are community health workers, the ones who make sure that patients do not slip through the cracks.

“Back there, you just get patients’ vitals,” said Martinez, motioning toward the exam rooms. “Here, it’s more knowing about them and making sure you can help them.”

That’s what she and Ortiz have done with Rebecca Whitaker. The 53-year-old Medicaid patient moved to Prineville last year, after shuffling through three Arizona nursing homes in six years, while recovering from a stroke.

Doctors had prescribed her 28 medications. Her social anxiety would get so bad that, sometimes, she rubbed her hands raw. By the time Whitaker got to Prineville to live with her cousin, she had given up on the health-care system.

… At Mosaic Medical, Whitaker received care for her diabetes and blood pressure. She also began seeing the clinic’s behavioral health specialist every week, who helped tend to her anxiety and depression.

Community health workers aided in other ways. They helped to ease her social anxiety by attending bingo night together. When Whitaker expressed an interest in moving out of her cousin’s house, Martinez helped her find an apartment.

“They have been the most moral support I’ve ever had in my life,” Whitaker said. “They cared, and that made me want to care. Little by little, when things got too frustrating in life, I’d see one of them. They changed my whole life.”

Ideally, everyone could get this kind of high-quality, coordinated care. Given limited state and federal dollars, though (states’ Medicaid programs rely on a combination of federal and state funding to provide coverage to low-income residents), states have to prioritize the most cost-effective interventions.

Healthcare use and outcomes
The researchers studying Oregon’s 2008 Medicaid expansion have used surveys, hospital data, and credit reports to assess Medicaid’s impacts at one year post-expansion and two years post-expansion. The results from the study measuring experiences one year after Medicaid enrollment (Finkelstein et al, The Quarterly Journal of Economics, 2012) were striking: the Medicaid enrollees had used more healthcare, including primary and preventive care as well as hospitalizations; had less medical debt; and reported having better physical and mental health compared to non-Medicaid subjects.

In the study of outcomes two years following enrollment (Baicker et al, NEJM 2013), the researchers collected blood-pressure measurements and blood spots from subjects as well as administering questionnaires, which included screening questions for depression. As before, they found that the Medicaid group used more healthcare, had less financial strain, and reported better health. This time, though, they also had data to measure clinical – as opposed to self-reported – outcomes, and the results were not so encouraging.

The researchers focused on four conditions that are important contributors to US health problems and might be expected to show improvement after two years of insurance coverage: hypertension, high cholesterol levels, diabetes, and depression. They reported, “Medicaid coverage did not have a significant effect on measures of blood pressure, cholesterol, or glycated hemoglobin.” (Glycated hemoglobin, or HbA1c, tests are used to diagnose diabetes and see how well the disease is controlled.) They did find that “Medicaid coverage led to a substantial reduction in the risk of a positive screening result for depression,” and that the Medicaid group had less financial strain from medical costs.

From the Oregon Health Study Group’s research, we can see that low-income Oregonians who received Medicaid coverage in the 2008 expansion benefited from it. Their patterns of healthcare utilization suggest that they were able to access healthcare, and they feel better mentally and physically. They also had less financial hardship, and that could be contributing to a sense of better health.

On most objective measures, though, the results of this experiment are disappointing. We hope that expanding insurance will make it easier for people to address conditions like high blood pressure and diabetes, and that better control of such chronic conditions will translate to fewer emergency-department visits and hospitalizations. The results from Oregon’s 2008 Medicaid expansion show that providing coverage doesn’t necessarily translate into improving health outcomes, at least not in a two-year time period for low-income adults.

Oregon Medicaid today
Wonkblog’s Sarah Kliff talked to Oregon officials who make an important point about the just-published study showing greater emergency-department use by Oregon’s new Medicaid recipients: It’s measuring the effects of the state’s 2008 Medicaid system, not the one that the new 2014 enrollees will find. The Oregon Health Authority now has data from the first half of 2013 (as opposed to the 2009 data behind the new study), and Kliff points out that rates of emergency-department visits by Medicaid beneficiaries have fallen, from 61 per 1,000 member-months in 2011 to 55 in early 2013.

The Oregon Health Authority’s latest metrics report also gives rates of Medicaid adult hospital admissions for complications from a few key chronic diseases. Admissions for diabetes complications rose slightly from 2011 to early 2013, but fell substantially for COPD or asthma and for congestive heart failure.

It appears that Oregon is seeing some initial encouraging results from efforts to improve the quality of care Medicaid recipients (and all Oregonians) receive. And it’s not the only state working to expand access to preventive and primary care for those who might otherwise end up in the emergency department. NPR’s Julie Rovner reported:

[The Oregon Medicaid emergency department] study doesn't come as much of a surprise to those people who actually run Medicaid programs around the country.

"This is not something that is unexpected and not something that we're not prepared for," says Kathleen Nolan. She's director of state policy and programs for the National Association of Medicaid Directors.

Nolan says most states are already working to help Medicaid recipients get care in more appropriate settings. "Things like nurse-advice lines, trying to work with the community clinics and community providers to expand hours and make sure that people who are working two and three jobs can get access to primary care after hours and on the weekends," she said.

The Affordable Care Act is an important first step toward improving US health outcomes. It does include investments in prevention, primary care, and changing payment systems to reward quality rather than just quantity of services provided, but its main effect will be on health insurance coverage. Efforts like Oregon’s ongoing one will be essential for finding cost-effective ways to assure that the newly insured have access to high-quality healthcare that improves health.


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