Why Medicaid Patients Receive Lower Quality Healthcare Research Paper

Excerpt from Research Paper :


Why are patients with Medicaid coverage not receiving the best quality of health care? One of the reasons is that physicians do not want to participate in the Medicaid program because the rate of payment from either the state or the federal government is slower than even that of private insurance (Brabury, 2015). As a result, access to quality care is limited for individuals who are enrolled in Medicaid. Another problem is that evidence-based practice (EBP) approaches to quality care are less likely to be utilized by physicians and nurses in facilities where Medicaid patients are accepted, thus reducing the quality of care that they receive (Calvin et al., 2006). Medicaid patients also tend to have poorer health and come from poorer backgrounds, which puts them at an additional disadvantage going in, as their health needs are more complicated and their outcomes less favorable, which impacts the perception of care received (Sastow et al., 2019). Finally, patients with Medicaid tend to experience greater treatment delays than individuals who are privately insured (Naghavi et al., 2016). Grembowski, Cook, Patrick and Roussel (2002) have analyzed the health care system from the perspective of exchange theory, which posits that the benefits and costs of an interaction between two parties are weighed to determine risks and benefits. Such an approach helps to understand why Medicaid patients receive lower quality care. However, patient-centered care is an approach that should be adopted regardless of how care is paid for, according to Connole (2012). An ever better theoretical approach for explaining how and why quality care should be delivered to all patients, including those on Medicaid, is adaptation theory put forward by Roy (2018). This paper will discuss the reasons Medicaid patients tend to receive lower quality care from health care providers, what theoretical approach explains this phenomenon, and what theoretical approaches can be applied to help address this problem.

Lack of Physician Participation

Although the Affordable Care Act (ACA) was supposed to increase the number of people who could receive health care coverage from the government, there has remained a problem in so far as physicians do not want to participate in the program because payment for their services is so slowly delivered (Brabury, 2015). The reason for slow payment is one part bureaucratic and another part regulatory. The bureaucratic machine of government is indeed hefty, but the government must also be on guard against fraud, as the majority of fraud is committed by those who apply for payment from the government. As the government is slow to verify the validity of payments, physicians and facilities would prefer not to be weighed down by this negative impact to their cash flow.

Lack of EBP Used in Medicaid-Participating Facilities

There is also a lack of EBP used among facilities that do participate in the Medicaid program (Calvin et al., 2006). EBP is important for providing quality care because it is based on the latest developments in research, whereas older methods of treatment and care can be based on outdated concepts or approaches that are either no longer relevant or have been found to be ineffective or inefficient over time. It is not a problem that Medicaid-participating facilities are unaware of EBP; rather, it is a problem that they often simply do not have the resources or funds available for implementing EBP.

Implementing new EBP means developing new protocols, policies and guidelines; training staff on new approaches and standards; developing measures, collecting data, evaluating outcomes, and reporting findings: it is a task that can be draining in terms of energy, time and resources. Facilities that are participating in the Medicaid program may already be tight on resources as a result of the first issue—the slowness of payments for services rendered. As facilities must wait on the state or federal government to render funds, cash flow is not at its most optimal, and budgets must be tightened year round, especially if there is an increase in the number of patients relying on Medicaid. The facilities tend to conduct themselves in a single, consistent manner, without regard for updating procedures, tools, equipment, policies and so on until absolutely necessary, simply because it requires investment.

Medicaid Patients Present with Poor Health Already

There is also a problem with Medicaid patients presenting with poor health already and coming from poor backgrounds. The more complicated their health care needs, the harder it is for Medicaid-participating providers to meet all those needs (Sastow et al., 2019). When those needs are not met, it creates the perception of low quality of care being received. Of course, it is not just a matter of perception, but also a matter of reality. Still, patients who are in poor health and from a poor socio-economic background…

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…be engaging in preventive care, it is against their business interests to do so. This is the conflict of interest at the heart of health care, and it has to be addressed.

Adaptation theory posits that a person can be viewed in terms of a system. The different aspects of the patient’s life come together to explain how the whole patient can be viewed by the health care provider: so instead of a nurse or physician seeing a Medicaid patient as a person presenting with one or two symptoms and thus needing certain tests and then treatments, the care provider looks at the whole person, that person’s environment, that person’s health history, that person’s mental, physical, emotional and spiritual state, and develops a holistic view of that individual. The provider then helps the patient to adapt to changes in the person’s environment or life so that a better state of quality of life can be achieved. The focus is on reaching a kind of equilibrium or balance between the person and the environment. Rather than force a certain type of health perspective or plan on the individual, the approach is tailored to help the individual obtain care that is right for them based on the needs identified through an exploration of the patient’s personal makeup and environmental makeup (Alligood, 2017). The purpose of the adaptation model is to allow the care provider to maintain compliance and to increase the life expectancy of the patient (Ursava?, Karayurt & ??eri, 2014). This would help the Medicaid patient to receive higher quality care comparable to what privately-insured patients receive.


The health care system in the US does not cater to the needs of Medicaid patients, as those patients tend to have complex health needs that can drain a provider’s time and resources without giving the provider recompense in an adequate manner to make up for the costs of giving treatment. This creates a problem from an exchange theory perspective. Practically speaking, care providers do not want to be at the mercy of a government regulatory agency that might end up denying payment because of some slip-up on the provider’s part. The more reliable patient from a for-profit perspective is the privately-insured patient. That is why providers cater to communities where privately-insured patients are more likely to be found. Access to care for Medicaid patients is thus limited, and that impacts…

Sources Used in Documents:


Alligood, M. (2017). Nursing theorists and their work. Elsevier.

Bradbury, C. J. (2015). Determinants of physicians' acceptance of new Medicaid patients. Atlantic Economic Journal, 43(2), 247-260.

Calvin, J. E., Roe, M. T., Chen, A. Y., Mehta, R. H., Brogan Jr, G. X., DeLong, E. R., ...& Peterson, E. D. (2006). Insurance coverage and care of patients with non–ST-segment elevation acute coronary syndromes. Annals of Internal Medicine, 145(10), 739-748.

Connole, P. (2012). Wireless data transfer from device to EMR. Provider Magazine, 1, 1-4.

Grembowski, D. E., Cook, K. S., Patrick, D. L., & Roussel, A. E. (2002). Managed care and the US health care system: a social exchange perspective. Social Science & Medicine, 54(8), 1167-1180.

Naghavi, A. O., Echevarria, M. I., Grass, G. D., Strom, T. J., Abuodeh, Y. A., Ahmed, K. A., ... & Caudell, J. J. (2016). Having Medicaid insurance negatively impacts outcomes in patients with head and neck malignancies. Cancer, 122(22), 3529-3537.

Roy, C. (2018). Spiritualty Based on the Roy Adaptation Model for Use in Practice, Teaching and Research. Aquichan, 18(4), 393-394.

Sastow, D. L., White, R. S., Mauer, E., Chen, Y., Gaber-Baylis, L. K., & Turnbull, Z. A. (2019). The disparity of care and outcomes for Medicaid patients undergoing colectomy. Journal of Surgical Research, 235, 190-201.

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