A new look at Medicaid expansion in Oregon found that it can take months or years for an enrollee to make improvements in their health.
De. Shaun Lan performs a skin exam on Kathryn Flack at Legacy Medical Group Northwest Clinic in Portland, Ore. Lan works with patients in the state's expanded Medicaid program, as well as with privately insured patients.(Photo: Rick Bowmer, AP)
WASHINGTON — New Medicaid patients in Oregon failed to use their benefits effectively because they did not understand how to use insurance or health care, according to a study released Monday in the journal Health Affairs.
As a result, researchers told USA TODAY, patients did not receive preventive health screenings, schedule appointments to manage chronic illnesses or use their new insurance coverage for anything beyond medical emergencies.
These findings, researchers said, should be considered in future health policy decisions, particularly those related to the Affordable Care Act and Medicaid expansion.
"There's this idea that health insurance is like car insurance: You use it when something really bad happens," said lead author Heidi Allen, an assistant professor at the School of Social Work at Columbia University and one of the co-investigators in the Oregon Health Insurance Experiment.
In 2008, Oregon used a lottery system to expand its Medicaid program. An initial study found no "statistically significant improvements" in physical health in the first two years, which meant no decrease in costs associated with poor health. A second study found increased emergency room use.
"After two years, we weren't really able to detect any differences, even though we knew people were using more care," Allen said. "Conservatives took that as evidence that Medicaid wasn't good insurance and that it shouldn't expand."
Instead, Allen found in her review of in-person surveys of 120 new enrollees that:
• People assumed if they used their insurance for something minor, like a physical, someone who needed care more might not get a turn.
• People knew they were using taxpayers' money and didn't want to waste it.
• Patients who knew they only had emergency dental care assumed that extended to all health care, so they went to the emergency room and not a regular doctor's office.
• Medicaid beneficiaries did not understand that preventive screenings could save the system money in the long term, or simply didn't know they should get an annual exam.
• People were afraid of how much they would be required to pay if they saw a doctor.
"This is a good opportunity to socialize people who may not have had health care for a really long time about how we want them to use health care," Allen said of her findings. "I see an opportunity for us to help patients understand, 'When this happens, this is where we want you to go.'"
Forty percent of new Medicaid enrollees didn't seek care very often because they didn't understand how the program worked, Allen said. When they did seek care, it was usually in an emergency. Nearly a third of these less-frequent users avoided care because they didn't know how much they would have to pay.
The other 60% of the 120 new enrollees surveyed used their insurance more often, but many also reported having difficulty understanding their benefits. Only about 10% used preventive care — and those consumers said they understood the benefits of preventive care. Ten percent said they saw immediate, marked improvement in their health because they were able to afford medications or a needed surgical procedure.
Of the regular users, just under half said they didn't feel like their doctors understood them or that they had very poor health that continued to get worse. Thirty-nine percent of the regular users said their health improved with insurance, but it took time. In those cases, the doctor tended to address the most-pressing health concerns first, and then work later on lifestyle changes that could help overall health.
"For the people that used health care on a regular basis over the three years, there was a group of people whose lives were just transformed," Allen said. "Those are people who had been waiting for surgeries, or needed a medication and felt so much better."
In one case, a 33-year-old man with debilitating back pain from a car accident walked with a cane. After two years' worth of treatment, he was able to walk without the cane, lost 80 pounds and stopped eating fast food. "No one would hire me walking with a cane," the man told the researchers. He said much of the weight loss came after he was able to get a job where he walked a lot.
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