Medicare for All Would Have Likely Resulted in Worse Pandemic Outcomes for Poor and Minority Communities, Data Shows

If data mattered, the ideological debate about what form of universal health insurance is best would already be over in the United States.

Whether or not one ideological extreme or another would like to admit it, the data increasingly shows that private health insurance, highly regulated by the government and in competition with one or more public options, delivers higher quality care than single-payer, government-provided care.

Even for people who face systemic economic and cultural (ethnicity/language) barriers. In fact, especially for people who face systemic economic and cultural barriers.

A study by the nonpartisan and objective research organization NORC at the University of Chicago puts a fine point on it: the NORC found that private Medicare, or Medicare Advantage (MA), plans yielded significantly better COVID-19 outcomes than traditional, government-paid, fee-for-service Medicare (FFS) for enrollees who are dual-eligible for Medicare and Medicaid.

Some might say that is because it's mostly white and relatively wealthier beneficiaries who actually choose private plans, so the better outcomes may be attributable to the systemic class and race advantages.

The data shows that precisely the opposite is true. First, in order to be dual eligible for both Medicare and Medicaid, beneficiaries have to meet strict income and asset criteria that place them firmly at the bottom end of the economic ladder. And the NORC study demonstrated that dual eligibles who choose Advantage plans are older, sicker, more female, and more ethnically and linguistically diverse than those who stick with the traditional government-payer plan.

It is the FFS (traditional) Medicare population that is weighed toward younger, healthier, whiter, and wealthier beneficiaries.

According to NORC data, of those within the dual-eligible population who choose to stay with the FFS plan, 6 in 10 (59%) dual-eligibles are under 65 (this is usually the population who have benefits due to disability), less than a quarter (23%) are between 65 and 74, and less than a fifth (18%) are 75 and above. By contrast, 39% of dual-eligibles who choose a private Advantage plan are under 65. Almost as many, 35%, are between 65 and 74, and 26% are 75+.

65% of dual-eligible Advantage enrollees are women, compared to 57% of FFS enrollees. 23% of dual-eligible Advantage enrollees are Black, and 32% are Hispanic, compared to 19% each for FFS enrollees. In contrast, fully half (49%) of FFS enrollees are white, compared to just 35% of beneficiaries who choose Advantage plans. 74% of dual-eligible FFS beneficiaries primarily speak English at home, and just 26% speak another language. Almost 4 in 10 (39%) of dual-eligible Advantage beneficiaries speak a language other than English at home.

MA duals also report having more chronic conditions than FFS duals. 56% of dual-eligibles who have Medicare Advantage have 4 or more chronic conditions, relative to just 46% of FFS dual-eligibles. More FFS beneficiaries were current smokers, and a slightly higher portion (22% to 19%) had a weakened immune system.

Dual eligible Advantage recipients also had more financial difficulties - in terms of affording food and rent - during the pandemic.

So how did the dual-eligible Medicare Advantage population that is poorer, older, more female, less white, and have at least as many comorbidities with COVID-19 as their dual-eligible FFS counterparts do? 

Private insurance participants - i.e. Medicare Advantage beneficiaries - had better outcomes from the pandemic by nearly every metric.

More than half - 51% - of FFS dual-eligibles reported that they were unable to get regular check-ups during the pandemic. Just 35% of Advantage duals said the same. 24% of Advantage duals were unable to get regular care for an existing condition, compared to 36% - almost a time and a half as much - of FFS duals. And most strikingly, one in five (18%) of dual-eligible FFS recipients were unable to get urgent care, compared to just 5% of Advantage recipients.

Part of this rather surprising gap in the outcomes for Advantage enrollees appears to be due to increased access to telemedicine during the pandemic. While just about the same portion of both populations - 1 in 6 - had access to telemedicine before the pandemic, almost two-thirds (63%) of Advantage beneficiaries reported having telemedicine access during the pandemic, contrasted with just about half (52%) of FFS participants.

It should be noted that although provided by private insurance companies, Medicare Advantage plans are highly regulated. They must accept anyone eligible for Medicare, and they accept, from the federal government, a sum of money that the government estimates would cost to care for a given beneficiary. They are required to provide a set of basic benefits that match traditional Medicare and can offer additional benefits.

As more and more people who are eligible for Medicare flock to private Medicare Advantage plans, one thing is becoming increasingly clear: private health plans, when highly regulated and forced to compete, are not just capable of delivering high-quality care to people regardless of income, wealth, age, gender, race, and health status of beneficiaries, they are often better at doing so than single-payer government options.

The data is showing, again and again, that allowing private health insurance to play a large, regulated, and competitive role in health coverage is the best way to ensure true universal, high-quality, care to every American. Medicare beneficiaries are proving it every day by choosing private Advantage plans in droves, and now we have definitive data that Advantage plans are providing superior outcomes to people who are particularly vulnerable.

We should, by no means, acquiesce to the right wing orthodoxy of deregulating and privatizing all healthcare, but as the side of politics that prides ourselves on our adherence to data and science, the left must acknowledge that a policy based more on the pitchfork-and-torches urge to punish private industry should not be prioritized at the expense of quality care for everyone, especially for the poor, people of color, and people living with chronic illness.

The Medicare-for-All orthodoxy among the left must end.

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