Medicaid Model Provides Best Path to Solving Crisis of the Uninsured

New England Journal of Medicine article proposes combining a Medicaid buy-in with an individual mandate

February 4, 2009 -- In a New England Journal of Medicine “Perspective” on universal health coverage, Michael Sparer, PhD, professor of Health Policy and Management at Columbia University Mailman School of Public Health, suggests that the most plausible path to covering the largest numbers of uninsured is to expand Medicaid. Dr. Sparer also argues that everyone should be required to carry health insurance and says that those whose income is considered too high for automatic coverage ought to have the option to buy into Medicaid. The article, “Medicaid and the U.S. Path to National Health Insurance,” is published in the January 22, 2009 issue of the Journal.

Medicaid is the most successful program in U.S. history for aiding those with incomes just above the federal poverty level and low-wage workers more generally. Medicaid has more than doubled its enrollment since the Reagan administration.

“The only plan with a chance of succeeding politically combines a Medicaid expansion and an individual mandate,” according to Dr. Sparer. He adds, “Relying on Medicaid is also good policy; it provides decent health insurance to more than 59 million Americans, and building on it is a much better idea than creating a brand new administrative infrastructure.”

“Previous efforts to enact universal coverage have failed in part because opposition from interest groups is far more influential than is organized support for uninsured low-wage workers,” says Dr. Sparer. “The failure can also be attributed to reform opponents who take advantage of the anti-government ethos that pervades our political culture, and our system of checks and balances which provides opponents with numerous opportunities to block legislation.” According to Dr. Sparer, however, a Medicaid expansion could plausibly overcome these obstacles. For starters,
since Medicaid is financed primarily with federal dollars, states can increase coverage while shifting much of the cost to the federal government. In addition, “business leaders support Medicaid expansion because it relieves the pressure on employers to cover low-wage employees.”

Dr. Sparer does point out, however, that there are obstacles to any type of national insurance plan, including the “Medicaid for More” approach. One roadblock might be convincing physicians to support a Medicaid expansion. “Typically, there are many office-based physicians who refuse to treat Medicaid patients, who cite low reimbursement rates and long administrative delays.” Dr. Sparer suggests that Medicaid agencies will need to pay higher rates or rely more heavily on nurse practitioners and physician assistants. A second concern is the stigma attached to the name itself. A solution might be to give the program a new name and thus a new identity as a middle-class entitlement.

While proposals for national health insurance have often failed, Dr. Sparer believes that expanding Medicaid in combination with an individual mandate might be politically appealing enough to succeed. He concludes, “If the recession and other priorities discourage President Obama from seeking universal coverage in one swoop, phasing in the model with a more modest Medicaid expansion is a good solution.”

About the Mailman School of Public Health
The only accredited school of public health in New York City and among the first in the nation, Columbia University Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting millions of people locally and globally. The Mailman School is the recipient of some of the largest government and private grants in Columbia University’s history. Its more than 1000 graduate students pursue master’s and doctoral degrees, and the School’s 300 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as infectious and chronic diseases, health promotion and disease prevention, environmental health, maternal and child health, health over the life course, health policy, and public health preparedness. www.mailman.columbia.edu