September 7, 2006
By Linda Gorman
People who want to expand government health care programs love to tell stories. An ancient fairytale currently climbing back to the top of the charts goes something like this: People who lack health insurance have no access to primary care. Because they have no access to primary care, their health problems go untreated. Minor problems become serious ones and people end up in the emergency room (ER). This costs money. You should pay more taxes so that we can save money by expanding Medicaid. Then people will have access to primary care, their minor problems will be taken care of before they become serious, and we will all save money.
This is a nice story. It makes people feel all gooey and sympathetic towards increased government spending on health care.
Fortunately, it isn’t true.
A number of recent studies show that the uninsured use the ER at the same rate as everyone else, and primary care coverage has little effect. In a study in Pennsylvania, ninety-one percent of asthmatics using the ER reported having a primary care physician. What characterized the frequent ER users was Medicaid enrollment, low education, and high use of other types of health care.
ER users with 5 or more visits in a year come because they are sicker. In Massachusetts, they were 1 percent of the 2003 emergency room population. They accounted for 17.6 percent of all visits. Their insurance status breakdown was 0.4 percent privately insured, 2.0 percent uninsured, 2.0 percent on Medicare, and 2.1 percent on Medicaid.
Zuckerman and Shen of the Urban Institute summarize the general conclusion: “The uninsured do not use more [ER] visits than the insured population as is sometimes argued,” they write. In fact “the publicly insured are overrepresented among [ER] users.”
Are the publicly insured overrepresented because Medicare and Medicaid patients are sicker? No one knows. The problem with accepting this explanation at face value is there is evidence suggesting that the government run programs, organizational nightmares that deliver poorer care at higher cost, may also do a poorer job of healing people.
In a cancer treatment study, 65 percent of privately insured people received guideline treatment. Just 60 percent of Medicaid and Medicare patients did. Children with juvenile rheumatoid arthritis on Medicaid used the same amount of health care as those with private insurance. They had similar joint involvement. But they also had higher disability and a lower health-related quality of life, possibly because public programs are a lousy way to deliver health care.