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 Critics of Medicare-for-all have raised concerns that it might lead
to a surge in use of inpatient services, because people with
comprehensive health insurance tend to use more hospital care than
people with bare-bones benefits, researchers note in the Annals of
Internal Medicine.
Some previous studies suggest this surge might materialize, but
other studies also suggest that hospital use only rises dramatically
when more beds are available and staffed for an anticipated spike in
utilization.
To see how universal coverage might play out today, researchers
looked at the two biggest expansions of health benefits in U.S.
history: the implementation of Medicare and Medicaid from 1966 and
the Patient Protection and Affordable Care Act (ACA) in 2014.
Using data from the National Health Interview Survey (1962 to 1970),
they found that hospital discharges averaged 12.8 per 100 people in
the three years before implementation of Medicare and Medicaid and
12.7 per 100 people in the three years afterward.
And based on data from the Medical Expenditure Panel Survey (2008 to
2015), with the ACA, discharges dropped from 9.4 per 100 people in
the three years before the law to 9.0 per 100 people in the three
years afterward.
"Contrary to expectations, overall hospitalizations didn't rise
after both expansions - suggesting that universal coverage
expansions like Medicare for All also won't cause a surge in
hospitalizations," said Dr. Adam Gaffney, lead author of the study
and president of Physicians for a National Health Program, an
organization that advocates for Medicare for All.
The expectation when previously uninsured people get health coverage
is that they will start using every kind of care, including hospital
care, driving up costs, Gaffney, also an instructor at Harvard
Medical School in Boston, said by email.
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In the current study, while some populations did increase their use
of hospital care, the increases were offset by reductions among
others.
For example, after the introduction of Medicare and Medicaid,
hospital use increased among elderly and low-income persons but
decreased among younger and higher-income persons.
This suggests that major coverage expansions result in shifts in who
uses the hospital, but not increases in overall hospital use, the
study team concludes.
One limitation of the study is that it only looked at hospital care
- which only accounts for about one-third of total healthcare
spending. These coverage expansions might mean something different
for outpatient or clinic visits, or prescription drug use, which are
also big drivers of health spending.
"When it comes to prescription drugs, there is no supply limit as
there is with hospital beds in the case of hospital care," Gaffney
said. "So we probably would expect a more unconstrained increase in
prescription drug use after Medicare for All, relative to hospital
care."
It's also possible that expanding insurance extends coverage mostly
to people who aren't at high risk of hospitalization, like young,
healthy people who rarely see doctors, said Dr. Anupam Jena, a
researcher at Harvard Medical School and Massachusetts General
Hospital in Boston who wasn't involved in the study.
"It's very clear from many studies that insurance expansion or
insurance coverage raises health care costs, despite the argument
sometimes made that better insurance leads to better primary care
which then leads to lower overall costs," Jena said by email. "That
isn't true - insuring more people costs more money, but for a
wealthy society such as ours, that in many people's minds is still
the right thing to do."
SOURCE: http://bit.ly/2K2bAYo Annals of Internal Medicine, online
July 22, 2019.
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