To the Editor:
The RAND Corporation is an independent research organization dedicated to improving policy and decision making through research and analysis. The only product we sell is the truth.
In that spirit, I take exception to John Goodman's depiction of RAND research in his March 25 Kaiser Health News Column entitled, "Is Medicaid Real Insurance?"
Goodman wrote: "A very comprehensive RAND study found that the type of insurance people have -- or whether they are insured at all -- does not affect the quality of care they receive."
The RAND study in question, "Who Is at Greatest Risk for Receiving Poor-Quality Health Care?" examined a large number of clinical charts to determine whether patients received recommended care for their health problems. This approach can tell you a lot about the quality of care patients receive once they've gained access to the system. It tells you nothing about those who are locked out.
The RAND team found that patients received recommended care only 55 percent of the time. Interestingly, quality-of-care scores did not vary much whether the patient was covered by Medicaid, Medicare, private health insurance or was uninsured. Goodman interpreted this to mean that Medicaid doesn't matter. By that logic, he could have reached the same conclusion about private health insurance.
But the RAND study was not designed to assess the value of health insurance; it was designed to examine the quality of American healthcare. Health insurance doesn't necessarily buy you better care; it gets you in the door. An Institute of Medicine committee I co-chaired reviewed a huge number of studies regarding the consequences of uninsurance and determined that uninsured adults get about half the care insured Americans receive. As a result, they tend to be sicker, and to die sooner, than Americans with health insurance.
This isn't the only study Goodman misinterpreted. Here's another: "If you're trying to get a primary care appointment, it appears your chances are better if you say you are uninsured."
If you click on the link, it takes you to a 2005 JAMA study entitled, "Insurance status and access to urgent ambulatory care follow up appointments." I was one of the study's co-authors. To find out if patients can get timely follow up care for potentially serious health problems identified in the ER, we asked research assistants to pose as patients and telephone a variety of primary care practices. We found that access to urgent follow-up appointments was bad across the board, but less bad for privately-insured callers than for Medicaid beneficiaries and the uninsured. The only scenario in which uninsured callers did better than Medicaid beneficiaries was when the caller said he or she was willing to pay the full visit fee in cash, up front. Goodman left this detail out.
The late Senator Daniel Patrick Moynihan once said, "You are entitled to your own opinion, but not your own facts." Mr. Goodman is entitled to express his views about the Medicaid program as forcefully as he wants. But he is not entitled to misstate RAND research, or the work of others, to make the case.
Arthur L. Kellermann, MD, MPH
Vice President and Director, RAND Health
Santa Monica, CA