Is Medicaid the best health care possible?

A lot of people who use it seem to think so.

A new study released by Harvard’s Chan School of Public Health shows that people enrolled in Medicaid are overwhelmingly satisfied with their coverage and care.

The researchers looked at survey data collected by the Centers for Medicare and Medicaid Services from more than 270,000 people who were enrolled in Medicaid in 2013. They gave the program an average rating of 7.9 out of 10, where 10 was considered “the best health care possible.” Nearly half of the respondents rated Medicaid a 9 or 10.

“If nearly half the people are giving it nearly a perfect score, that’s pretty good,” says Michael Barnett, a researcher in the Department of Health Policy and Management at Harvard’s Chan School. “There aren’t a lot of services that we get for anything, government or not, where you’d give it a perfect score.”

The study, published as a research letter in the July 10 issue of JAMA Internal Medicine, also shows that 84 percent of Medicaid recipients felt they were able to get all the medical care they needed in the last six months. Only 3 percent said they could not get care because of long wait times or because doctors would not accept their insurance.

The results applied across the board to those in traditional Medicaid, Medicaid managed care plans and among the elderly and disabled. The study did not include people who got Medicaid through the Affordable Care Act expansion or people in nursing homes.

The survey results come just as Republicans in the Senate are debating a complete overhaul of the Medicaid program, and they counter some of the major arguments for those changes.

House Speaker Paul Ryan, who has championed the Medicaid overhaul, often argues that many doctors refuse to accept Medicaid patients.

“I mean, what good is your coverage if you can’t get a doctor?” he asked in a presentation to reporters in March.

Health and Human Services Secretary Tom Price made a similar argument in testimony to the House Ways and Means Committee last month.

“One-third of doctors in America do not accept new Medicaid patients,” he told the committee. His office didn’t respond to a request for comment on the new study.

Barnett, the study’s author, says the new data is the first that shows what Medicaid users think of the program.

“Part of what motivated this study is that there is a lot of rhetoric and what we would call misinformation around ‘What does Medicaid do, how effective is it, and how satisfied are enrollees with their coverage?'” he says. “This is the survey that really provides the most reliable large scale information that we have to date, [with] over 270,000 enrollees, and they’re largely satisfied.”

The bill being considered by the Senate would slowly roll back the expansion of Medicaid benefits to many poor, non-disabled adults, that happened as part of the Affordable Care Act, or Obamacare. And it would change Medicaid from an open-ended program that pays for all the care beneficiaries need, to one that offers states a set amount of money each year based on the number of people who qualify for Medicaid in that state.

The analysis issued by the Congressional Budget Office last month estimates spending on Medicaid would be $770 billion less over ten years under the Senate bill than under current law and that 15 million people would lose Medicaid coverage by 2026.

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Women who have high-risk pregnancies or complications in childbirth are up to eight times more likely to have heart disease later in life, statistics suggest. But many mothers — and their doctors — are unaware of the danger.

Emerging research shows heart disease is a long-term threat for women who develop diabetes or high blood pressure during pregnancy, for example. Also at higher risk: mothers whose babies were born too small or too soon.

Yet doctors typically do not advise these mothers about their risk or counsel them to watch for heart disease symptoms, says Dr. Noel Bairey Merz, cardiologist and director of the Barbra Streisand Women’s Heart Centerat the Cedars-Sinai Heart Institute in Los Angeles.

Bairey Merz says doctors can see heart attacks and strokes coming, often 10 or 20 years ahead of time — if they are on the lookout.

“This isn’t rocket science,” she says. “We just have to figure out how we can find the women who are at risk.”

One such woman, Lara Hogan, gave birth to her son Zion at Cedars-Sinai in May of last year.

Sitting in her living room in Topanga Canyon, Calif., Hogan, who is now 41, recounts how she monitored her blood pressure throughout the pregnancy because she had been treated for hypertension in the past. Then, during her 36^th week, her blood pressure spiked — a sign of the emergency condition known as preeclampsia.

Hogan and her husband, Chad, headed to Cedars-Sinai, where doctors told her they needed to deliver the baby that night.

But her blood pressure didn’t come down after she gave birth — it kept rising.

“They had someone standing at my bedside monitoring me, in case anything happened,” Hogan recalls. “I guess they were so nervous that I was going to have a stroke.”

She didn’t. But her baby stayed in the neonatal intensive care unit for eight days, and Hogan went in and out of the hospital as doctors tried to lower her blood pressure.

“It was a nightmare,” she says. “All I’d dreamt about was this moment for so many years. It was like the opposite of everything I thought it would be.”

Finally, the doctors were able to use medicine to bringing her blood pressure down. They referred Hogan to a postpartum heart health program led by Margo Minissian, a nurse scientist at Cedars-Sinai. Over the next several weeks, Minissian and Hogan’s doctors helped her get to a proper dosage and routine that enabled her to stay out of the hospital.

Since then, Hogan has checked her pressure most days and plans to continue seeing doctors to manage her long-term cardiac risk. Zion, who recently celebrated his first birthday, just started walking and likes to play with his toy xylophone and drums.

Hogan hopes to have another baby soon, so has been checking in with Minissian again, to make sure her blood pressure is well-controlled before she gets pregnant. And now she knows she is at risk for heart disease later in life because of the complications surrounding Zion’s birth.

“As much as I don’t want to be thinking about my future heart health, or worrying about what’s going to happen when I am older,” Hogan says, “this is priority No. 1 for my health right now — for the sake of my son and my future children.”

Heightened awareness of the link between pregnancy complications and heart disease is prompting greater outreach to the public, and to collaborative research between cardiologists and obstetricians. That could help “make tremendous strides toward reducing and preventing heart disease in women,” says Bairey Merz.

About 80 percent of U.S. women give birth to at least one baby, and one-fourth of those have complications during the pregnancy or labor. Researchers are still trying to figure out why these complications would be linked to later heart problems. Pregnancy might contribute to vascular complications, they suggest as one hypotheses — or it might simply reveal existing problems.

“Pregnancy can really mimic the stressors of age,” Minissian notes. Pregnancy, she says, could be “a woman’s first physiological stress test.”

To further explore the heart disease connection, Cedars-Sinai recently started following a small group of women who had pregnancy or labor complications. In a separate study, Bairey Merz and other researchers, funded by the National Institutes of Health, are tracking the health of 5,000 new moms at eight sites across the nation, to fill gaps in knowledge and develop recommendations for physicians.

The Women’s Heart Alliance, an advocacy group, started by Cedars-Sinai and New York-Presbyterian Hospital/Weill Cornell Medical Center, is also working with obstetricians and other providers to raise awareness of this particular heart risk among women and their doctors.

“We’ve got a big advocacy and education piece that we should be doing together,” says Dr. Barbara Levy, vice president of health policy for the American Congress of Obstetricians and Gynecologists. Cardiologists and women’s health care providers are in a unique position to drive the research agenda, Levy says.

For now, women who have had complications in pregnancy or labor should alert their primary care doctors and have annual screenings for high blood pressure, Minissian says.

The American Heart Association and American Stroke Association also recommend that women who have had preeclampsia be evaluated for heart disease risk within a year of giving birth. Some may need medication or a referral to a cardiologist.

But most new mothers with less serious complications during pregnancy needn’t rush to see a cardiologist, Levy says — they just need to eat healthfully, be active and get enough sleep. Immediately referring all these women to specialists could result in undue anxiety and unnecessary medical tests, she says. Not good for a busy new mom.

“It will cost a lot of money and a lot of her time while she is dealing with a baby,” says Levy.

As part of the Cedars-Sinai project, Minissian screens certain women for cardiovascular risk within six months of delivery and follows up with them every year. She also tries to help them lead healthy lives to “avoid the whole heart disease trajectory altogether.”

“These women are going to have their eyes wide open,” Minissian says. “They are going to be looking for it, and they won’t allow people to pat them on the back and say, ‘Oh don’t worry about that high blood pressure.’ “

This story is part of NPR’s partnership with Kaiser Health News. KHN is an editorially independent news agency funded by the Henry J. Kaiser Family Foundation. Follow Senior Correspondent Anna Gorman on Twitter @annagorman.

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Americans really, really don’t like the Senate bill to repeal and replace the Affordable Care Act.

Only 17 percent of U.S. adults approve of the health care bill, according to a recent NPR/Marist/PBS NewsHour poll. In fact, a majority of Americans now approve of the ACA, also known as Obamacare — but just nine months ago, that wasn’t true.

So what do they want?

Maybe they want single-payer health care — a slight majority of Americans now say they would like that kind of system, according to the Kaiser Family Foundation. But then, they don’t like it once they hear about the trade-offs. So maybe they simply want Obamacare to go further — that’s what a plurality of respondents told NPR. Or to be more specific, they favor most Obamacare provisions…but not the individual mandate (which is needed to make the ACA work). Or they want to keep the Affordable Care Act but scrap Obamacare (or vice versa).

Some of this uncertainty is perhaps to be expected — as a certain president has pointed out, health care is “complicated.” But if lawmakers are looking to Americans to know what their next move should be, they could be waiting a while. Messy, contradictory, easily swayable opinions on health care are a common theme in American politics, as it turns out.

Inconsistent, changeable opinions

Recent polls on health care show a few areas where Americans’ views on health care are less than clear:

1) Single-payer

A slight majority of the population — 53 percent — approves of a single-payer system, according to a new Kaiser Family Foundation poll, up from 39 in the early 2000s.

But then, the Kaiser pollsters found that they could easily — and substantially — swing that 53 percent by presenting people with potential arguments for and against a single-payer system.

When people heard the argument that the system would “give the government too much control over health care,” opposition rose from 40 to 62 percent. But on the other hand, when presented with the argument that a single-payer system would “reduce health insurance administrative costs,” the share of Americans in favor swung from 55 to 72 percent.

…all of which makes logical sense (people can be swayed by arguments for and against a particular policy — who knew?). But it suggests that it may be a mistake to take Americans’ support or opposition for a given health care policy at face value.

Moreover, in a more intense debate over single-payer, all of these arguments would be made at once, meaning many Americans could easily be swung from one side to another or simply left in a “don’t know” place.

2) Obamacare is relatively popular now. It wasn’t before.

Obamacare was never a super-popular policy. But it did suddenly become more well-liked just after President Obama left office. According to data from Gallup, the law hit its highest popularity ever in April, at 55 percent approval — the first time it ever had majority support in Gallup’s polling (which began in 2012). And that swing was despite the fact that nothing major changed in Obamacare in recent months that would easily account for that swing.

3) Government responsibility for health care has also grown more popular

Relatedly, Americans during the Obama presidency were closely divided over whether the government is responsible for making sure “all Americans have healthcare coverage,” and at times a majority believed it was not the government’s responsibility.

But before the Obama presidency, a majority of Americans consistently said yes, and a majority once again do, according to data from the Pew Research Center and Gallup.

4) Only some of Obamacare is popular

When it comes to Obamacare, Americans tend to like many of the provisions: they like people being able to stay on their parents’ insurance until age 26, and they like the idea of exchanges. But they don’t like the individual mandate — the fact that people must buy insurance or pay a penalty. In fact, as the Kaiser Family Foundation found, out of seven Obamacare provisions, the individual mandate was the only one without majority support.

“The elements of the Affordable Care Act are more popular than the act itself,” said Kathleen Weldon, director of data operations and communications at the Roper Center for public opinion. “And that’s largely a political question.”

Again, this isn’t necessarily surprising — the threat of a penalty is understandably less appealing to many than the convenience and security of the age-26 provision. But it does show that what Americans want doesn’t always match up with what is feasible — that individual mandate is a big part of what makes the Affordable Care Act work.

“It would be very hard to put together a functional health policy that wouldn’t have some elements that people disliked,” said Weldon.

5) Obamacare vs. ACA

As of February, 35 percent of Americans didn’t know the Affordable Care Act and Obamacare were the same, according to polling organization Morning Consult…a fact famously hammered home when late-night TV host Jimmy Kimmel asked people on the street of Los Angeles whether they favored the Affordable Care Act or Obamacare.

None of this is new

Inconsistent opinions on health care have been around for a long time. In one 2001 review of 50 years of public opinion data, for example, experts remarked that “it is striking to see how many conflicting views the public holds on health policy issues,” before laying out an array of messy public views:

“On the one hand, Americans report substantial dissatisfaction with our mixed private/public health care system and with the private health insurance and managed care industries. A majority of Americans indicate general support for a national health plan financed by taxpayers, as well as increased national health spending. On the other hand, these surveys portray a public that is satisfied with their current medical arrangements, in many years does not see health care as a top priority for government action, does not trust the federal government to do what is right, sees their federal taxes as already too high, and does not favor a single-payer (government) type of national health plan.”

Much of this sounds familiar today — indeed, a majority of Americans now believe that it’s government’s responsibility to make sure people have care, but an overwhelming majority of Americans also distrusts the government.

“Over the years these conflicts in beliefs have been difficult to resolve in legislative debates, particularly around the issues of large-scale national health care reform. This is likely to remain the case in the years ahead” they wrote — something lawmakers on Capitol Hill know all too well.

So what do Americans want?

Americans’ views on health care are hard to understand for a number of reasons. One is a lack of knowledge. Some of that knowledge is basic — not knowing there is no difference between the ACA and Obamacare, for example — but many Americans may also not understand how the individual mandate makes other parts of Obamacare work.

Another reason is fear.

“There are some things we do know. Americans fear big changes on something that is an acutely sensitive subject,” said Karlyn Bowman, an expert on public opinion at the right-leaning American Enterprise Institute.

She compares it to another policy area Congress continually talks about overhauling.

“In tax reform, change is not at all concerning. It’s just so interesting,” said Bowman. “[Tax policy] is so much less sensitive than health care, which scares the heck out of us because we don’t understand it.”

But that fear is nuanced. People like the broad idea of change, said Ashley Kirzinger, senior survey analyst at the Kaiser Family Foundation, a health policy research organization. But it’s the particulars that scare people off.

“People kind of have this enthusiasm for health reform,” she said. She points to the Affordable Care Act. “Once it became a plan that had pros and cons and winners and losers, favorability tends to fall off rather dramatically.”

But then, it’s those very particulars that may have made more Americans suddenly decide they approve of Obamacare.

“A lot of the attitudes towards the ACA and why we’re seeing this trend upwards in favorability is because people weren’t quite sure what was in it, and once they’re hearing about benefits being taken away, then it’s really like, ‘Oh, but we really liked that.'”

And then there’s politics. On all of these questions, there are, of course, sharp political divides driving people’s opinions. The Affordable Care Act became widely known as Obamacare, meaning that many Americans (that is, those who know the two are synonymous) may have linked their approval of the act with their approval of Obama.

Given all this, there are still at least a couple of constants in Americans’ views on health care. Kinzinger says one pops up over and over again.

“Always lower costs,” she said. “When individuals say they want health care reform, what they mean is they want to reduce their own costs when it comes to health care. Premiums, deductibles, any of that. It’s all about cost.”

But most Americans have a more selfless instinct as well, Bowman added.

“[Americans] generally want us to try to cover more people, to give more, because we’re such a generous people,” she said. “We really want to move to that end. But I don’t think we’re very knowledgeable about specifics.”

It’s not that people’s opinions don’t matter or that they’re always unclear — clearly, Americans dislike the Senate bill (according to an Axios analysis, it’s the most unpopular major legislation in 30 years).

But what they want is also hard to deliver — plenty of politicians would certainly like to know how to bring down America’s extremely high health care costs once and for all, and to make sure all Americans can get health care coverage if they want it. But doing so without scaring voters too much, whether it’s by trade-offs or the simple act of overhauling the system, may well be impossible.

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Republican senators are trying to revive their health care bill. While voters weren’t fond of the the original version, but they’re not always clear about what they want when it comes to health care.

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It was about a year ago that Ornella Mouketou walked into the emergency room at the George Washington University Hospital in Washington, D.C., and told them she wanted to end her life.

She was in her early 20s, unemployed and depressed.

“I was just walking around endlessly. I was walking around parks, and I was just crying all the time,” she says. “It was like an empty black hole.”

She spent a few days in the psychiatric ward at the hospital, and while there, she met a case manager from the McClendon Center, a mental health agency. That person followed up after she went home and is still in touch with her now.

“They kept in contact with me. They came to my house,” says Mouketou, who now takes a prescription mood stabilizer and has weekly therapy sessions at the McClendon Center to manage her depression.

Today, Mouketou has a job at a CVS pharmacy, earning $11.50 an hour, and she’s working toward becoming a pharmacy technician.

“I love my job,” she says. “It’s crazy, and it’s fun.”

All of Mouketou’s care has been paid for by her Medicaid managed care insurance plan, run by AmeriHealth.

Mouketou, 25, qualifies for Medicaid only because Washington, D.C., agreed to expand the program as allowed under the Affordable Care Act. If the Senate’s health care bill becomes law, Mouketou’s access to Medicaid would likely disappear in a few years.

“That will be heartbreaking,” she says.

One of the little-talked-about effects of the Affordable Care Act, or Obamacare, was to boost access to mental health care for the poor. For people like Mouketou, access to mental health care can mean the difference between being able to hold down a job or not.

Linda Rosenberg, president of the National Council for Behavioral Health, says the expansion of Medicaid has helped many people who were unable to work, or who earned very little, boost their opportunities. The National Council represents non-profit and public mental health care centers, including the McClendon Center in D.C. where Mouketou gets her care.

“People of all economic roots have mental illness,” she says. But she notes it’s especially hard on the poor, because it “affects your ability to work, because you have a brain disorder. And if it affects your ability to work, it’s going to affect your ability to get promoted and to make a living.”

Under the health bill being considered in the Senate, states that expanded Medicaid would see the federal money that helps pay the costs of that additional health care ratcheted back over four years, starting in 2020. States would still have the option of offering health care to the expansion population, which consists of adults with incomes up to 133 percent of the federal poverty level. However, lower federal reimbursement rates mean few states would be able to afford it.

The rollback would not only affect people like Mouketou, but also the programs that benefit her and other low-income people with mental health issues.

The McClendon Center has expanded its services, including opening a new counseling center, precisely because most of its patient care is now paid for under the Medicaid expansion, says CEO Dennis Hobb. He says 85 percent of its income is from Medicaid.

“It’s been great for those folks, because before, they didn’t have any mental health benefit,” he says.

Hobb says the center has worked with AmeriHealth Caritas, D.C.’s biggest Medicaid managed care provider, to develop an intense intervention program for people in mental health emergencies like the one Mouketou experienced.

“When any patient is admitted to a psychiatric hospital, we go in, and we follow them for 30 days,” he says. If someone goes to an emergency room and is not admitted, McClendon seeks them out at home within seven days and assigns a case manager.

The result? The readmission rates of people with mental health emergencies fell among McClendon’s client population.

“You’re saving money by putting it up front and getting people the services they need,” Hobb says. “That’s cheaper. It saves money down the line.”

Hobb worries all that progress will be reversed if the money from Medicaid is withdrawn. “I think what would really happen is that a lot of people would go back to how it was eight years ago, when people weren’t getting what they needed.” Hobb says people with severe mental illness die, on average, 25 years earlier than the general population.

“People die because they don’t have good health care,” he says.

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A little-discussed provision in the Senate health care bill is designed to boost the number of hospital beds for psychiatric care, providing a long-sought victory for mental health advocates.

The provision would amend an obscure rule regarding Medicaid funding — a rule that has sharply limited the number of beds for those with schizophrenia, bipolar disorder or other mental illnesses.

Yet leading advocacy groups on mental health issues say they see no reason to celebrate.

That’s because the Senate bill would also wring out $772 billion from Medicaid — the joint state-federal insurance program that is the single-largest provider of care for people with serious mental illness. The nonpartisan Congressional Budget Office has said that the Senate bill, drafted by Republicans as a replacement for the Affordable Care Act, would reduce overall Medicaid spending by 26 percent by 2026, and by 35 percent the following decade.

The loss of those funds would devastate health care services for people with mental illness, who are some of the most vulnerable and disadvantaged people in the country, said Bethany Lilly, deputy director of policy and legal advocacy at the Bazelon Center for Mental Health Law, an advocacy group.

“Medicaid is the safety net for people with serious mental illness,” said Ronald Honberg, senior policy adviser at the National Alliance on Mental Illness.

Without decent mental health care and support services, people who have a psychotic disorder can quickly deteriorate, Honberg said, ending up in overcrowded emergency rooms, jail and prison cells or dangerous city streets. “This bill is a prescription for making all these problems worse.”

Republicans who crafted the Senate bill have noted that Medicaid spending will still increase under their plan — just at a rate lower than currently projected. The Senate bill will make Medicaid spending more sustainable, said Julia Lawless, a spokeswoman for the Senate Finance Committee, one of the Senate committees that oversees health legislation.

“Even before Obamacare’s unprecedented Medicaid expansion,” Lawless said, “the program was plagued by quality issues. States were barred from using innovative solutions to improve patient care and both federal and state Medicaid spending was growing at unprecedented, unsustainable levels.”

The Senate bill will reverse this course, she said, and slow the growth of Medicaid “without cutting actual benefits.”

The Medicaid program has traditionally refused to pay for inpatient stays in large, freestanding psychiatric facilities, making exceptions for patients under age 21 and facilities with 16 beds or fewer. The rule, which has changed little since Medicaid was created five decades ago, was aimed at preventing the federal government from paying for long-term care in psychiatric institutions.

But that Medicaid rule also has contributed to a severe shortage of psychiatric beds for people in crisis, said John Snook, executive director of the Treatment Advocacy Center, a nonprofit that focuses on people with serious mental illness.

Mental health advocates have called for changing the rule for decades.

Last year, the Centers for Medicare & Medicaid Services eased the policy, paying for up to 15 days of inpatient hospital care for patients enrolled in Medicaid managed-care plans. But in a letter to the Medicaid program last year, the National Association of Medicaid Directors noted that some patients with mental illness or substance abuse disorders might need closer to a month of inpatient care.

The current draft of the Senate bill, dubbed the Better Care Reconciliation Act, would allow states to receive federal matching Medicaid funds for up to 30 consecutive days of inpatient psychiatric hospital care, or 90 days in a year.

This suggested change in Medicaid funding was included in the Republican bill because several senators have voiced concern that patients haven’t had enough access to hospital care for mental illness and addiction, according to a GOP Senate aide who was authorized to speak only on condition of anonymity. The legislators involved, according to the aide, included Sen. Orrin Hatch, R-Utah, and Sen. Rob Portman, R-Ohio.

Honberg said he would welcome such a change except that reducing overall Medicaid spending could force closures of rural hospitals and institutions that serve as “safety nets” — providing free care to people who are uninsured or poor.

If these hospitals go out of business, Honberg said, the total number of hospital beds available to people with mental illness could shrink, not expand.

Medicaid, he pointed out, pays for a wide variety of supportive services for people with schizophrenia and other serious mental illnesses — beyond doctor’s visits and medications. States can use Medicaid funds to pay for case managers; transportation of patients to and from doctor’s appointments; supportive housing, which helps people with serious mental illness live independently; supported employment, which provides job training and other services; and teams of professionals who assist people who need intensive, comprehensive help navigating the health system and social services.

Kaiser Health News, a nonprofit health newsroom, is an editorially independent part of the Kaiser Family Foundation.Follow KHN’s enterprise reporter Liz Szabo on Twitter@LizSzabo.

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