4 Things Paul Ryan Misses About Medicaid In His New Poverty Report


On Monday, House Budget Committee Chairman Rep. Paul Ryan (R-WI) released a major new report entitled “The War on Poverty: 50 Years Later,” an exploration of major government safety net programs meant to combat hunger, extend access to health care, and buttress financial security for the poorest Americans. Ryan argues that Medicaid — the state-federal partnership program that provides health insurance for impoverished Americans, and is being expanded significantly under the Affordable Care Act — is ultimately an inefficient program.

Ryan does acknowledge several advantages to the program, which has been proven to reduce medical debt, improve mental health, and reduce mortality among beneficiaries. But he still uses selective research to make the case that Medicaid is failing low-income Americans. Here are four things that the congressman misses about Medicaid:

1. Fewer people die in states with more generous Medicaid programs, and beneficiaries report better health.

Ryan does note research finding that Medicaid coverage reduces mortality in certain states, including New York and Arizona. But he ultimately concludes that Medicaid coverage has “little effect on patients’ health.”


That’s not entirely accurate. In fact, Ryan even contradicts that same assertion in another section of the report on enrollees’ care utilization. He cites a study in which a group of uninsured Oregonians were randomly enrolled in Medicaid in 2008 after the state expanded eligibility criteria. Researchers found this group to have “substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations)… and better self-reported physical and mental health than the control group.” Ryan also cites another part of the Oregon Medicaid study finding that “Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication.”

Ryan’s main argument seems to be that people with Medicaid don’t fare quite as well as people with private insurance. But that’s because he’s comparing two distinctly different populations of people — uninsured Americans and the poorest who eventually gain Medicaid coverage are originally sicker to begin with, compared to the typically wealthier Americans who can afford private insurance or receive it through an employer. For instance, Medicaid enrollees are far more likely to have diabetes compared to those with other insurance sources. These health disparities can be attributed to a variety of environmental and socioeconomic factors, including social exclusion and a lack of access to healthy foods.

As the Kaiser Family Foundation (KFF) notes, Medicaid coverage has proven time and time again to be vastly preferable to being uninsured, especially since the uninsured are far more likely to lack a usual source of care or have an unmet health care need. The very Oregon study that Ryan mentions finds that Medicaid adults were “25 percent more likely to report they were in good to excellent health (versus fair to poor health)” and 40 percent less likely to report health declines in the last six months.

2. Medicaid gives the poorest Americans financial stability.

Although Ryan’s report notes that Medicaid beneficiaries have significantly lower levels of medical debt and catastrophic medical expenses, it also argues that Medicaid can exacerbate employment inequality among the enrolled.


The congressman supports this notion by citing several studies finding that female heads of household and low-income pregnant women who have Medicaid are less likely to participate in the labor force. But this mirrors an argument recently adopted by Affordable Care Act critics claiming that Obamacare will eliminate the equivalent of 2 million full time jobs, and is a misleading way to interpret the situation.

The higher labor force participation among uninsured people or those covered by employers may actually indicate that there are a number of people who are only working because they need enough money to afford some semblance of medical care. Low-income mothers or female heads of household may find it preferable to stay home as caretakers in the absence of adequate preschool and child care programs. Medicaid coverage is also extremely beneficial for new mothers and pregnant women, who are more likely to seek out prenatal care, well-child visits, and dental care for their kids.

3. People with Medicaid are just as satisfied with their coverage as those with private insurance.

The poverty report takes pains to paint Medicaid as an inferior alternative to private insurance. But Ryan entirely ignores a recent Government Accountability Office report finding that Medicaid beneficiaries are just as satisfied with their coverage as people with private plans.

Since 2008, a host of states have taken steps to make their Medicaid programs more enticing, including by cutting down administrative red tape for providers and increasing payment rates to doctors. The GAO report finds those efforts have largely been successful, and that “less than 4 percent of beneficiaries who had Medicaid coverage for a full year reported difficulty obtaining medical care, which was similar to individuals with full-year private insurance.”

That provides some context to Ryan’s assertion that Medicaid beneficiaries have a harder time getting care because just one-third of physicians don’t plan on accepting new Medicaid patients. In fact, anywhere between 10 and 18 percent of doctors don’t accept private insurance, either. While it’s true that specialty and dental care is harder to access for Medicaid-insured Americans due to low reimbursement rates, Ryan conveniently leaves out the fact that the ACA boosts those payments by an average of 73 percent through next year.

4. Higher emergency room use in Medicaid isn’t permanent.

One of the most controversial findings in the Oregon study that Ryan cites throughout the report is that the state’s Medicaid expansion caused a 40 percent increase in trips to the emergency room — something that cause Obamacare opponents to further question the wisdom of the health law’s Medicaid expansion. Health care experts do agree that the ER is expensive and the wrong place for medical treatment, and that most care should occur through preventative and primary care doctor visits. But Ryan fails to point out several nuances within that statistic.


In January, an emergency medical physician from Washington state told ThinkProgress that an initial rise in emergency room use by newly-insured people is entirely expected. “Why do they go to the emergency rooms first? Because old habits are hard to change. In the past, they’ve always been able to go to an emergency department, so initially that’s where people return to, because prior to this they didn’t have access,” said Dr. Stephen Anderson. “Anybody that’s followed the progress of the last 15 years or so shouldn’t be surprised by these findings. If you look at the initial rollout in Canada, if you look at the initial rollout in Massachusetts, there was pretty much across the board increased use of emergency services when the programs first went into effect.”

In fact, past evidence in Massachusetts showed that emergency visits were reduced between five and eight percent in 2012 compared to 2007, when the state’s own comprehensive health reform law was adopted. In Oregon, coordinated care organizations that manage care for Medicaid enrolless has successfully lowered emergency room visits and spending, ushered patients into primary care doctors’ offices, and even reduced the incidence of hospitalizations from heart failure and catastrophic pulmonary illnesses.

Cutting Medicaid benefits or increasing the eligibility threshold could actually be much worse for ER spending. A review by the American Academy of Orthopedic Surgeons about disenrollment from Medicaid and the Children’s Health Insurance Program in Phoneix found that “a 10 percent disenrollment from the Phoenix metropolitan area’s Medicaid/SCHIP program would increase overall healthcare costs to the community by $3.5 million or $2,121 for each disenrolled child… mainly due to the shift from less expensive, preventive medicine and ambulatory care to more emergent and inpatient care.”