Posted on November 21, 2006

Medicaid coverage worse than private insurance?


Insurance Coverage and Care of Patients with Non-ST-Segment Elevation Acute Coronary Syndromes

By James E. Calvin, MD; Matthew T. Roe, MD, MHS; Anita Y. Chen, MS; Rajendra H. Mehta, MD, MS; Gerard X. Brogan, Jr., MD; Elizabeth R. DeLong, PhD; Dan J. Fintel, MD; W. Brian Gibler, MD; E. Magnus Ohman, MD; Sidney C. Smith, Jr., MD; and Eric D. Peterson, MD, MPH
Annals of Internal Medicine
21 November 2006

Background: The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear.

Objective: To compare NSTE ACS care patterns by insurance type.

Design: Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage.

Setting: 521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005.

Patients: 37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older.

Measurements: Guideline-recommended treatments, and in-hospital outcomes.

Results: Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18).

Limitations: Self-pay patients and patients without insurance were not assessed.

Conclusions: NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation.

Grant Support: CRUSADE is funded by Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, also provided funding for this research.

Potential Financial Conflicts of Interest: Consultancies: M.T. Roe (Schering-Plough, Bristol-Myers Squibb, Sanofi), E.M. Ohman (Savacor, Liposcience, Responsible Biomedical, The Medicines Company, Inovise): Honoraria: J.E. Calvin (Millenium Speaker’s Bureau), M.T. Roe (Sanofi, Bristol-Myers Squibb, Schering-Plough); Stock ownership or options (other than mutual funds): E.M. Ohman (Inovise, Savacor, Medtronics Inc.); Grants received: M.T. Roe (Schering-Plough, Bristol-Myers Squibb), W.B. Gibler (Schering-Plough, Bristol-Myers Squibb, Sanofi-Aventis), E.M. Ohman (Bristol-Myers Squibb, Sanofi-Aventis, Schering-Plough, Millenium Pharmaceuticals, Eli Lilly Inc., Berlex).


By Don McCanne, MD

It is important to understand this study because it will be used by the opponents of government health insurance programs to “prove” that private plans provide higher quality care and improved health care outcomes compared to government programs.

Perhaps the most important point to note is that private plans were contrasted with two different government programs - Medicaid and Medicare - and the conclusions were that only Medicaid was associated with worse outcomes, and Medicare was not.

As an insurance program, Medicaid has more comprehensive benefits and much lower out-of-pocket spending than do the private plans or Medicare.

Therefore the difference cannot possibly be explained by a greater ability of private plans to eliminate financial barriers to health care, a crucial function of insurance. Unfavorable socioeconomic factors undoubtedly play a significant role. The Medicaid program is chronically underfunded, which reduces the financial incentives for physicians and hospitals to care for these patients. Also, many physicians strive to create a practice with a classier clientele. Anyone who has spent any time in the doctors’ dining room has heard countless complaints from physicians who have had another (censored) Medicaid patient dumped on them by the ER (while the more dedicated physicians at the table lose their appetite and become silent). You do not need hard data to surmise that an angry physician who wants to rid himself of his welfare patient would not be as compulsive about a checklist for ACC/AHA compliance.

The other government program studied, Medicare, rather than being a welfare program for the poor, is a program of social insurance in which almost everyone over 65 participates. Medicare patients are largely welcomed by physicians and should and do receive at least the same level of care as privately insured patients. If anything, the conclusion that should be reached based on this study alone is that private plans did not provide any advantage over Medicare even though private Medicare Advantage plans are paid on average 15 percent more than is spent on patients in the traditional Medicare program. Even though quality and outcomes on these limited measures were the same, value provided by the private plans was worse because it cost more for the same outcomes.

Why were these data pulled out of the CRUSADE study? Why were the uninsured excluded from this subset of data? Did the authors really wish to prove that Medicare could produce the same results at a lower cost?

Several of the authors have alliances with the pharmaceutical industry, and the CRUSADE study was supported by pharmaceutical company grants. The pharmaceutical industry is currently partners with the private insurance industry in combating a move toward publicly-funded and publicly-administered universal health insurance.

A cavalier quote by James Calvin, the lead author, is revealing: “On the surface, people may conclude that doctors have a bias against poor people. However, it doesn’t cost a thing to tell someone to watch the salt in their diet or to quit smoking, which is really good advice to reduce heart problems.” (

What is that line? When they say it’s not about the money, it’s about the money.