A lot of things are worse than not having health insurance. For one thing, “Death does not appear to be a short-term consequence of being uninsured.” This reassuring conclusion comes from Baker et al. in a paper on health insurance coverage, overall health, and death among the near elderly.

Now that we have been assured that people who become uninsured are not immediately struck dead, perhaps health policy research community can move on to looking at the effects of payer type on patient outcomes. There are scattered results in the literature that suggest that Medicaid coverage produces worse outcomes than private insurance coverage even after differences in socioeconomic factors have been adjusted for. In a few cases, being on Medicaid may be worse than being uninsured. Settling this question would have important implications for health care reform. If Medicaid coverage produces worse results than private coverage, then caring reformers should stop focusing on herding greater and greater numbers of people into Medicaid and start considering ways to facilitate the purchase of private insurance.

Medicaid patients with heart problems get poorer care than those in HMOs or with private insurance. People on Medicaid and Medicare are less likely to be prescribed newer drugs for oral glycemic control. In New Jersey, 5 to 7 years after diagnosis breast cancer patients with local or regional disease had an adjusted risk of death that was 40% higher if they were on Medicaid than if they had private insurance. A study of cancer survival in Kentucky found that survival rates for the privately insured were 10 to 15% higher for the privately insured than for the uninsured for breast, colon, prostate, and lung cancer. Those who were uninsured had higher survival rates than those with “unknown insurance type or Medicaid/welfare. Harlan et al. studied the receipt of guideline therapy by cancer patients, and concluded that the treatment received by the uninsured was as likely to adhere to clinical recommendations as that of the privately insured.

In studying HIV-related mortality, Bhattacharya, Goldman and Sood concluded that insurance does protect against premature death, that private insurance is more protective than public insurance, and that the difference is explained by Medicaid prescription drug policies that limit access to new and effective treatments. Brunner et al. found that children with rheumatoid arthritis who were on Medicaid appeared to have similar health resource use, but higher rates of disability.

The protective effect of private insurance also shows up in nationalized health care systems. In an abstract on European men with prostate cancer with what researchers termed “uninhibited access” to health care, the results suggested that “In univariate analyses addressing pathological variables, private insurance was invariably protective” and that the privately insured “had a lower rate of BCR [biochemical recurrence] after RP [radical prostatectomy].” Obviously access was not uninhibited, but scientists are not necessarily good economists.

Finally, as Brian Schawartz ably points out in an Independence Institute op-ed, Medicaid’s low payment rates and ridiculous paperwork makes many physicians unwilling to take Medicaid patients. Government is really, really good at promises. Whether they are sufficient to encourage others to provide the care you need is another matter entirely.