I'm reading Avik Roy's book (pamphlet) on Medicaid. I have some strong opinions on this topic. In 1965, when Medicare and Medicaid became law, I was a medical student at the Los Angeles County Hospital. My experience has been that the big city hospitals that once served as the safety net for the urban poor, were devastated by the new law. Medicaid (MediCal in California) would not pay for care in the County hospital where resident physicians were often the providers. I knew men who quit their residencies to start MediCal mills.
Years later, after I had done a graduate program at Dartmouth, I asked permission of the new MediCal administrator to study the results of an HMO model versus a fee for service model. I had the funding and the academic support. Permission was refused.
The author does an excellent job of describing the evolution of Medicaid and the effects on the poor. I have never changed my mind about the benefits of the previous model, using big community teaching hospitals to treat the poor. Medicaid promised them "mainstream private care" which they have never had and will not have under Obamacare. Many primary care docs I knew when I was in practice would treat Medicaid patients and never bill the system because the payment was so poor and it took two years to get paid. They were in practice in a prosperous community. Many inner city docs had no choice but were unable to provide good quality care. Medicaid was never a real choice for the poor.
Good account and well worth reading. His last section advocates a free market system for the Medicaid population. I tend to doubt its efficacy and think the basic safety net would be stronger in a system that included teaching hospitals and clinics. There is a reason most poor people are poor. For years after Medicaid began we would get patients coming to the County Hospital clinics for a second opinion, then going back to the private second rate hospital because of the amenities. They trusted us but liked the semi-private room.