Why would an organization billed as a “respected source of health care data” publish an analysis with mutually contradictory conclusions? In the case of the Kaiser Family Foundation, the answer is simple: To defend Obamacare—even if the facts don’t align with one’s conclusions.
As conservatives have noted for years, Obamacare encourages states to discriminate against individuals with disabilities—a prime example of how government intervention in the health care system ultimately hurts those the left claims they want to help. Liberals, understanding the political power of such charges, feel compelled to push back on this narrative. While they don’t have many actual facts with which to do so, that hasn’t stood in the Kaiser Family Foundation’s way.
Obamacare’s Discrimination, Explained
Ultimately, the discrimination comes down to simple math. States receive anywhere from a 50-76 percent match from the federal government to cover their pre-Obamacare populations—including individuals with disabilities. By contrast, states receive a 93 percent match this year, and a 90 percent match beginning next year, to cover able-bodied adults.
If you could gain 50-76 cents for doing one thing, and 90 cents for doing another, which would you choose? I know which I would.
When I served on the Commission on Long-Term Care in 2013, it explored an area of health policy unknown to much of the public: Hundreds of thousands of individuals with disabilities remain on Medicaid waiting lists for home and community-based care. While federal law requires state taxpayers to pay nursing home benefits for all eligible Medicaid patients, coverage of community-based services remains optional, so states can—and do—establish waiting lists to control their Medicaid spending.
These waiting lists preceded Obamacare, so Obamacare didn’t cause the waiting lists per se. And individuals with disabilities on the waiting lists do have their health care needs paid for by Medicaid, even as they wait to become eligible for home-based care (e.g., help with bathing, dressing, etc.). But sheer common sense indicates that states will prioritize coverage of able-bodied adults—for which they get paid a higher match from the federal government—than eliminating their waiting list for individuals with disabilities.
The Flawed Premise
For Kaiser—a liberal think-tank that broadly supports Obamacare—the waiting lists present a political problem. They have published data on Medicaid waiting lists since 2002. But the waiting lists have only grown since Obamacare took effect. When I first wrote on the issue, before the law’s Medicaid expansion began, states had 511,174 individuals with disabilities on waiting lists. As of 2017, the waiting lists stood at 707,378—an increase of 38.4 percent since that 2010 survey.
For the past several years, Kaiser has attempted to rebut charges that Medicaid expansion has affected waiting lists for individuals with disabilities. Their studies, including one released in April, claim that there is no relationship between whether a state has expanded Medicaid and increases or decreases in its waiting lists.
However, as I first noted two years ago, Kaiser’s over-simplistic analysis does not begin to consider the many other factors that affect decisions about their Medicaid programs and waiting lists. To use the most obvious example, the average state that has not expanded Medicaid is poorer than the average state that has. Connecticut, with a median income of $73,781 in 2017, has more resources to expand Medicaid to able-bodied adults and reduce its waiting lists than a state like Alabama, which had a median income of $46,472.
If Kaiser wanted to do a thorough analysis, it would control for this variable, and others. For instance, a good econometric analysis would factor in states’ morbidity rates—because states with sicker populations may have more individuals with disabilities needing care—along with the underlying cost of care, because states would have to spend more to reduce their waiting lists in areas with higher prices.
If it wanted to explore the issue of Medicaid waiting lists and Obamacare in-depth, Kaiser has had several years to undertake a good economic analysis examining many of these factors, to determine more definitively the relationship between Obamacare’s Medicaid expansion and waiting lists for individuals with disabilities. Instead, it continues to peddle superficial and simplistic conclusions—conclusions that just so happen to support Obamacare.
How superficial are Kaiser’s conclusions? The section of its April paper right after the passage claiming no relationship between Obamacare and waiting lists includes this doozy:
Waiting lists are a function of the populations a state chooses to serve and how the state defines those populations; both of these factors vary among states, making waiting lists an incomplete measure of state capacity and demand for [home and community-based services] and not directly comparable among states. [Emphasis original.]
If waiting lists for individuals with disabilities are “not directly comparable among states,” then why did Kaiser in the preceding section claim Obamacare’s Medicaid expansion has nothing to do with waiting lists—a conclusion that by definition involves comparing waiting lists among states?
The question practically answers itself. Kaiser just hopes you won’t notice.
Talking Point versus Research
When Kaiser released the brief in April, I reached out to the brief’s lead researcher, to point out that the “study” made mutually contradictory claims. After summarizing the weaknesses in the research methodology outlined above, I said the paper seemed like “a politically motivated conclusion—that Medicaid expansion did not disadvantage those on [home and community-based services] waiting lists—in search of cherry picked ‘facts’ to meet its pre-set outcome.”
After more than two months, the researcher, Mary Beth Musumeci, would not deign to defend her “research” with a direct reply. Instead a Kaiser spokesman sent me what amounted to a polite brush-off, replicated in full below:
Thank you for your interest in our work. We appreciate people taking the time to consider our work and provide constructive feedback on it, and our team discussed your comments and ideas.
The data in the brief are presented as a simple, descriptive comparison of trends in wait lists stratified by expansion status, and we also tried to be clear about major limitations of the data, including caveats in state comparisons of wait lists. While we agree that further econometric analysis to assess causality could build on this work and contribute to policy understanding, the posted brief was not an attempt to undertake such analysis.
We appreciate your feedback and will consider it as we continue to develop our work in this area, and we hope our work serves as a useful basis for your own analysis and econometric research to undertake the type of work you suggest in your comments.
I responded with one simple question: Does the Kaiser Family Foundation have any plans to conduct an econometric study on Medicaid expansion and waiting lists? As I noted in my response:
You’ve admitted the limitations of your own analysis to date, but you’ve repeated these types of assertions for several years—without doing the type of in-depth research that you concede would be both warranted and more accurate. Why not?
Kaiser’s communications department responded that they don’t have that type of study planned. I won’t hold my breath for them to conduct this type of econometric study, either. As with the issue of pre-existing conditions, Kaiser won’t ask a question to which it doesn’t want to know the answer. Far better to use a crude and highly flawed “study” to claim that Obamacare hasn’t affected Medicaid waiting lists—the political conclusion the Kaiser analysts want to support.
A supposed “fact check” on the disability waiting list issue two years ago called the Kaiser Family Foundation a “respected source of health care data.” But by issuing mutually contradictory conclusions to maintain a political talking point, and not conducting the in-depth research that they admit the issue of Medicaid waiting lists warrants, Kaiser again reveals itself not so much as a respected source of health care data as a highly liberal one.