Top Republicans made the media rounds this weekend saying it doesn't matter if the Congressional Budget Office finds that millions fewer Americans will have health coverage under their Obamacare repeal-and-replace bill.
Democrats, healthcare providers and many health policy experts say it matters a lot. That's at the heart of the battle over the future of the Affordable Care Act, which extended coverage to 20 million uninsured Americans.
Repealing the Affordable Care Act's Medicaid expansion and reducing premium subsidies for private insurance will have little impact, Republican leaders say. What really counts, they say, is whether more people will have affordable access to physician care and other medical services.
“That's what we're trying to fix,” Mick Mulvaney, director of the Office of Management and Budget, said Sunday. “Not coverage for people … but care they can afford. When they get sick, they can go to the doctor. … That's where we think it is going to be wildly successful.”
Some Republicans go further, arguing that having a health insurance card is virtually useless. “Medical insurance for the poor is often a piece of paper that cannot be converted into actual care because Medicaid reimbursement, especially in California, is so low,” Hugh Hewitt, a prominent conservative talk show host said on NPR Monday.
Those who are skeptical of the value of Medicaid coverage often cite a 2013 study published in the New England Journal of Medicine which found that Oregon residents who gained Medicaid coverage during a 2008 lottery had no greater rate of detection of hypertension or high cholesterol than a comparable group that did not gain coverage.
On the other hand, the study found those who gained coverage had a lower rate of depression and enjoyed greater financial protection from medical bills. Those Oregonians with Medicaid visited doctors' offices more often and had more prescriptions compared with those who didn't get covered.
“It seems clear from a wide body of evidence, not just the Oregon study, that people with Medicaid report access to higher quality care than if they were uninsured,” Katherine Baicker, a health economist at the Harvard School of Public Health who co-authored the study, said in an interview.
More evidence that Medicaid coverage matters came in a 2014 study published in the Annals of Internal Medicine, which found the death rate in Massachusetts dropped significantly after that state adopted mandatory coverage in 2006.
The researchers reported the number of deaths per 100,000 residents fell by about 3% in the four years after the state's healthcare reform law went into effect. The drop was sharpest in counties in Massachusetts that had the highest percentages of poor and previously uninsured people. In contrast, the death rate in similar counties in other states that did not expand coverage was largely unchanged during that period.
Many patients and providers agree that expanding Medicaid coverage to low-income adults has been a good thing. In January, Louisiana Democratic Gov. John Bel Edwards marked the one-year anniversary of his state's expansion by introducing three Medicaid beneficiaries who said the expansion may have saved their lives by covering their cancer care.
Edwards ticked off the numbers of Medicaid expansion beneficiaries who had received preventive services, which in some cases had detected potentially life-threatening illnesses. Since the expansion started last June, 50,000 Louisianans have received preventive care; 5,000 women completed diagnostic breast imaging, including 63 who were diagnosed with breast cancer; 2,200 patients were newly diagnosed with hypertension; and 4,400 people had screening colonoscopies, including 1,100 who had precancerous polyps removed.
Financial protection was a big benefit for Tedi Wright, 61, a waitress in Charlottesville, Va., who earns about $30,000 a year. She bought subsidized ACA coverage through the federal exchange in 2015, after being uninsured for many years. Her plan paid more than $100,000 to cover her bills when she was diagnosed with colon cancer. That saved her from having to sell a house she rents out, which she is counting on for retirement income, in order to pay those medical bills.
Talk show host Hewitt, who's based in Orange County, Calif., argued on NPR that under the GOP bill, federal block-grant dollars would help states and local governments fund the delivery of primary-care services for low-income people. Then “the good elements of the community will band together to deliver actual care,” he said. “No one will be worse off from a medical care standpoint.”
But Orange County providers don't see it that way. David Becerra, community relations manager for the Coalition of Orange County Health Centers, said the ACA's Medicaid expansion had allowed the county's community health centers to serve 60,000 more patients a year and significantly expand the range of services they offer, including behavioral health.
He flatly disagreed with Hewitt's upbeat assessment of what would happen under the GOP bill. “If the expansion is repealed and that funding is eliminated, the community would still expect us to fulfill that need. Our centers would take a significant hit.”
Dr. William Conway, CEO of the Henry Ford Medical Group, used stronger words in responding to the GOP argument that expanded Medicaid coverage doesn't help people. "It's fake news," he said. "Medicaid expansion promotes a healthier population through easy access to services and prevention."