Insurance is just a first step towards improving access. Also important is whether that insurance helps people to get the care that they need. In a recent report from the Urban Institute, John Holahan, Michael Karpman, and Stephen Zuckerman probed that question. They surveyed people between ages 18 and 64 in September of 2015 as part of the Health Reform Monitoring Survey. They focused on people who had incomes below 400% of the federal poverty line, and thus would be eligible for either subsidies or Medicaid.
It's important to remember that this group makes up all of the people who get Medicaid and more than 80% of those who obtain private insurance on through the exchanges. Most people who do not get insurance from their jobs qualify for some level of tax credits to help them obtain insurance.
First, researchers queried whether people had a "usual source of care". Only about half of people who were uninsured for part of all of the last year answered yes. But about three-quarters of those with employer-sponsored insurance (ESI), Medicaid, private exchange, or non-exchange private insurance answered in the affirmative. Insurance of any stripe improved things greatly. Only about 41% of the uninsured had a checkup lin the last year, compared to 65%-70% of all other with any type of insurance. On the other hand, people with Medicaid had the most trouble getting a doctor's appointment (19%), compared to other types of insurance (9%-14%) and the uninsured (12%).
Almost 40% of the uninsured had an unmet health care need in the past year because of cost. Of those with private insurance, 27%-29% had such an unmet need. Of those with Medicaid, though, only 21% had an unmet health care need because of cost. This is likely because Medicaid has very low (if any) deductibles or co-pays, let alone premiums. Cost is not nearly as much of a barrier.
Similarly, while 28% of the uninsured had problems paying medical bills in the last year, only 22%-26% of people with private insurance did. Only 16% of those with Medicaid reported such problems. This is - again - because of out-of-pocket costs. Only 17% of the uninsured has out-of-pocket costs of more than $1500 in the last year. Contrast that with 21% of those with exchange private plans, 24% of those with ESI, and 32% of non-exchange private plans. Only 8% of those with Medicaid met this barrier. The uninsured and those with Medicaid also had no deductibles. About 46% of those with exchange private plans, 33% of those with ESI, and 45% of non-exchange private plans had deductibles of at least $1500.
When asked about satisfaction with their plans, answers differed as well. With respect to choice of doctors and providers, the highest levels of dissatisfaction were seen among those with private exchange plans (14%). Both Medicaid and non-exchange private plans had 10% dissatisfied with choice in this area. Only 6% of those with ESI were unhappy with their choice of doctors. With respect to premiums, more dissatisfaction was seen, including 31% of those with non-exchange private plans, 25% of those with exchange private plans, and 21% with ESI (compared to only 8% of those with Medicaid). When asked about satisfaction with protection from high medical bills, answers were similar, with dissatisfaction of 26% of those with non-exchange private plans, 25% of those with exchange private plans, and 17% with ESI, and 8% of those with Medicaid.
In many ways, this is good news. The vast majority of people with all types of plans are satisfied with their choice of physicians and providers, even those with Medicaid, contrary to many media reports. People are less satisfied with the costs of insurance, and with the protection they receive from high costs, but - again - Medicaid seems to do well there, too.
We do, however, still have too many people with unmet health care needs because of costs. Too many avoid care because of the cost, and too few people have a usual source of care. Ironically, in many of these areas as well, Medicaid seems to do better than private insurance.