Randomly Assign Medicaid and Study?
February 12, 2014 1 Comment
My friend and Duke colleague Chris Conover suggests that states caught in the coverage gap due to their decision to not expand Medicaid (people too poor for exchange subsidies, but not eligible for Medicaid; WSJ says ~20-25% of the uninsured in North Carolina fall into this category) should consider a replication of the Oregon Medicaid experiment in which people were randomly assigned to Medicaid. States could then study the results.
There is merit to the idea in a State whose political leadership is uncertain about Medicaid expansion, and especially when some invoke the Oregon study as a reason to not expand Medicaid (I am not going to rehash that debate now). If multiple States undertook such an experiment,it would provide a great deal more evidence about the impact of coverage expansions, particularly given the idiosyncratic attributes of States. If North Carolina did this, we would need to very carefully design the study; for example, the Oregon study actually only included residents of Portland, as Chris notes in his piece, and we would need to make sure we invested enough resources in the study to provide definitive answers. North Carolina would especially need to make sure we could understand how such an experiment worked in both rural and urban areas.
My suggestion that North Carolina expand insurance coverage using a Basic Health Plan under Section 1331 of the ACA could certainly have an experimental component built into it. In fact, North Carolina could seek authority to do a BHP along side a Medicaid waiver, and randomly assign those below 100% of poverty to traditional Medicaid, or the private insurance/provider option that I proposed in the BHP. The comparison would then be to determine if the private coverage option differed from traditional Medicaid in terms of outcomes.
My white paper Don Taylor NC Health Reform Proposal 1 14 14 goes beyond health insurance expansion and calls for a demonstration/test of an alternative medical malpractice and patient safety approach among those newly covered, and efforts to expand the supply of health care providers by lessening regulation and expanding the practice authority of non-physician providers are also included. We should seek comprehensive reform efforts, and not only focus on coverage expansion.
The ACA has quite a lot of flexibility built into it for States, and the Obama administration has shown a willingness to allow States to experiment with different models and approaches. States like North Carolina have tremendous political leverage that we are now wasting. There are many potential approaches and models. North Carolina needs to pick one and move ahead with a coverage expansion that informs overall system reform, and commit to evaluating and learning from the results.