Our guest blogger is Harold Pollack, the Helen Ross Professor of Social Service Administration at the University of Chicago. This post originally appeared on The Incidental Economist.

A morning phone call with Austin leads me to make a few additional points about that Medicaid audit study I noted yesterday.

First, it’s clear from this study and others Medicaid reimbursement rates are a real problem. So is our state’s often deplorable public management, greatly worsened by our budget crisis. The quality of governance matters. We have to do better.

It’s odd to see low Medicaid reimbursement rates trotted out as a conservative talking point, especially when some advocates who speak most vociferously about this problem oppose what is required: spending more money to address the problem. The Affordable Care Act relies more heavily on Medicaid than many liberals wanted. This was the outcome a political bargain with fiscal conservatives who sought to constrain federal spending.

I have been writing about this problem for years. So has pretty much every other liberal advocate for health reform. These problems are imperfectly addressed in the Affordable Care Act. There was better blocking and tackling on these points in the House version than in the final bill. Still, attention was paid to primary care reimbursement, to community health centers, and related matters. Whether the money will be appropriated is another matter.

Every bipartisan compromise being floated to constrain Medicaid spending, including proposals to relax state MOE requirements, would make these problems worse. Absent greater federal support, the arithmetic is pretty daunting. We can and should address Medicaid fraud, pursue disease management programs, and more. These measures will improve the quality and integrity of Medicaid services. I see little reason to believe they will produce big savings.

To reiterate: There are only so many ways to curb the level and the growth of Medicaid spending: Cover fewer people, cover fewer services, or underpay providers even more severely than we currently do. It just speaks volumes about Washington’s political process that we focus like a laser beam on curbing one of the very few notably under-funded components of our health care financing system.

Second: audit studies usefully document the extent that we have a segmented health care delivery system. They do not directly compare the experiences of low-income Medicaid recipients with the experiences of low-income people who hold alternative private coverage. This particular study compared Medicaid with Blue Cross Blue Shield, probably the best private coverage in the area. BCBS is pretty costly, in part because it allows broad access to diverse providers. Cheaper private plans offer more limited access through a narrower network of providers. That’s true at my own employer, which offers excellent benefits.

Third: People ask: Is Medicaid better or worse than private insurance in gaining access to needed care? Having Medicaid is obviously better than being uninsured. Yet it is difficult and probably misplaced to give a broad thumbs-up or thumbs-down answer to the basic question. One should give different answers for different people, who face different challenges in their access to medical and social services.

Within that NEJM study, patients faced serious but basic issues: A broken bone, diagnosing type I diabetes, and so on. Medicaid patients can get reasonable, no-frills access to safety-net providers who address these concerns and who have genuine expertise in addressing the challenges people face in low-income communities. In serving these patients, a key policy challenge is to provide a financially sound infrastructure which ensures high-quality and dignified services within this network of care.

Medicaid is designed for patients with complex medical and social service needs. There is no genuine private-sector equivalent for many Medicaid services provided to disabled individuals with special needs. Medicaid is also designed—and this is important–for patients who have no money. My wife and I care for a dual-eligible individual who has faced complex and costly service needs. We have encountered many issues with his Medicaid coverage. He has not faced financial difficulties related to his insurance coverage.

If you are a low-income worker whose child has a costly illness, your private insurance could easily impose crushing financial burdens. The Affordable Care Act makes great progress on this front through regulatory measures that limit out-of-pocket spending, rescissions, and more. Still, if one’s child has a $500,000 cancer diagnosis, Medicaid provides better protection against medical bankruptcy than private insurers are likely to do.

These are the strengths of Medicaid. Yet thinking about that $500,000 cancer, you would probably want your child to receive excellent care from the best provider. If your mother experienced a heart problem or a strange diabetes complication, you would want her to receive care from the most technically proficient specialists. This week’s NEJM study suggests that this might be hard. Many specialists are very reluctant to take Medicaid patients.

Disparate access to technically proficient providers and hospitals means a lot to individual patient. It also matters at the population level, for example in explaining black-white health disparities. Pressing harder to broaden access, to raise the quality of safety-net providers, and to strengthen Medicaid itself are key challenges in improving public health. These are also major efforts pursued within the Affordable Care Act.

The New York Times’ Denise Grady reports that children in Medicaid have a harder time accessing health care than enrollees in private health insurance:

Children with Medicaid are far more likely than those with private insurance to be turned away by medical specialists or be made to wait more than a month for an appointment, even for serious medical problems, a new study finds.

Lower payments by Medicaid, delays in paying and red tape are largely to blame, researchers say.

The study, with findings that match anecdotal reports from other parts of the country, is one of only a few efforts to measure access to health care among people with Medicaid. Nationwide, those patients are caught between states’ threats to cut Medicaid payments and the Obama administration’s plans to use the program to cover more and more people as part of its health care law.

The obvious worry is that Republicans will seize on the study to push for greater Medicaid cuts in the debt ceiling negotiations — arguing that a program that fails to provide adequate coverage deserves a place on the chopping block. But for all of Medicaid’s problems, its access challenges cannot be addressed by allowing states to push large numbers of beneficiaries off of their rolls or lowering reimbursement rates any further; that would only jepordize existing coverage.

A recent report from First Focus found that Medicaid typically offers “a broader range of services, including preventive care and special services needed by those with disabilities or other chronic conditions” at access levels that are actually “comparable to access provided under private health insurance and far better than access available to the uninsured.” In fact, “almost all children covered by Medicaid or CHIP children have a usual source of care” and “about nine out of ten publicly- and privately-insured adults had a usual source of care, compared to less than half of uninsured adults.”

Austin Frakt also points out that “Finding that some proportion of doctors doesn’t accept one type of insurance is not the same thing as finding a disparity in health outcomes caused by differences in access.” “Private plans have networks. Some are broad and some are more narrow. The study compared Medicaid to a plan with a very broad network, BCBS. By the study’s methods, individuals in plans with more narrow networks would have less access than BCBS enrollees,” he notes. That’s an important point that should caution policy makers from jumping to broad conclusions about the Medicaid program and prevent them from making any further cuts to it.