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Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m40 (Published 05 February 2020) Cite this as: BMJ 2020;368:m40

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Illness should not inflict financial ruin

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We can reduce out-of-pocket costs – but at what price? Re: Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study

The study by Gotanda, et al is an interesting look at the out of pocket costs, for care reported, for individuals covered by the Affordable Care Act (ACA) Medicaid expansion program. It is not however a study of the QUALITY-OF-CARE provided OR the CHOICE-OF-CARE provided to these individuals.

There are several reasons why out of pocket expenses can decrease. The first would be an actual improved quality of care - with the patient’s office and hospital visits being covered in addition to the costs of testing, prescription drugs and other related health care costs. That of course is the inference being made by this study and a Medicare-for-All approach. It is NOT however what is shown here.

There are unfortunately multiple other reasons – which are not covered in this study – which can also explain why reductions in out of pocket costs can occur. Including inter alia:

1. Decisions to NOT seek medical care because the provider the patient is required to see, is different from the provider they would CHOOSE to see, if they had another insurance.

2. Decisions by patients to not seek medical assistance due to costs and their expectations that they will NOT receive the same QUALITY of care provided to people with private insurance. Expectations that are at least to some extent founded by what is and isn’t covered under this Government run healthcare program.

3. Decisions about whether the patients can afford to fill prescriptions under the Affordable Care Act (ACA) Medicaid expansion, given the continued run away prescription drug prices resulting from an uncontrolled BigPharma.

4. Decisions not to undergo medical testing due to the refusal of the ACA to cover such tests.

5. Decisions to avoid hospital admission due to failure of ACA coverage of such admissions or the requirement that they most go to a hospital different from the one they would CHOOSE to go to if they had private insurance.

While this is by no means an all-encompassing list, it does demonstrate the tiered - cast system - level of medical care resulting from a Government Lawyer run healthcare system.

It would be nice to think that this study showed something more important than merely the number of dollars people paid out of pocket. It would be nice to think this study showed better healthcare for these people as a result of being part of this Government Lawyer run healthcare program – but it does not.

Gotanda, et al have shown that we can reduce out-of-pocket costs – but at what cost to quality and Choice?

Competing interests: No competing interests

13 February 2020
Richard M Fleming
Physicist-Cardiologist
Matthew R Fleming, BS, NRP (FHHI-OI-Camelot); Tapan K. Chaudhuri, MD (Eastern Virginia Medical School)
FHHI-OI-Camelot
Los Angeles, CA, USA