More than 20 U.S. state governments betrayed the health and well-being of their residents five years ago when they decided against expanding Medicaid pursuant to the Affordable Care Act (ACA) aka Obamacare. Now, thanks to a just published study, we have a good idea of the human cost: nearly 16,000 deaths over the four-year period from January 2014, when the expansion initially took effect, through the end of 2017.

The study, released on July 21, looked at what would have occurred if Medicaid had been expanded nationwide in 2014. Based on the differences in mortality between states that expanded and those that didn’t, the study found that 15,600 deaths in the non-expansion states would have been prevented if those states too had expanded Medicaid.

The flip side of that finding, of course, and one that the study does not quantify, is the tens of thousands of people who are alive today in those states that did expand Medicaid, as a result of that expansion. The website indicates that as of July 2018, New Jersey had 1,745,725 covered by Medicaid and its companion program, Children’s Health Insurance Program, or CHIP.  (NJ CHIP covers children in households with income up to 350 percent of the Poverty Line, one of the most generous thresholds in the country.) Of that number, 470,874 were added as a result of the ACA expansion, leading to a 42% reduction in the number of New Jerseyans who lack health insurance.

Published by the National Bureau of Economic Research as Working Paper 26081, the study report bears the unsexy title Medicaid and Mortality: New Evidence From Linked Survey and Administrative Data. The authors are: Sarah Miller, assistant professor of business and public policy at University of Michigan Ross School of Business; Laura Wherry, assistant professor of medicine at UCLA’s Geffen Medical School; Sean Altekruse, an epidemiologist with the National Institute of Health; and Norman Johnson, a statistician with the National Census Bureau.

The Medicaid program, established by the federal government in 1965, is a state-federal partnership that provides health coverage to low-income individuals.  States are not required to participate but all of them do and the program presently covers more than 72 million adults and children, roughly one-fifth of the U.S. population. The federal Centers for Medicare and Medicaid Services (CMS) monitor how states administer the program but states still have a lot of leeway in determining eligibility and benefits.

Prior to enactment of the ACA, the federal government paid half the cost of Medicaid, sometimes as much as 74%. Also, pre-ACA, the eligibility cutoff varied widely, ranging from a low of 16% of the Federal Poverty Level in Arkansas to 215% in Minnesota. As of 2013, the year before the Medicaid expansion took effect, the national median was 61% of the Poverty Level for working parents and 37% for jobless parents, according to the Kaiser Family Foundation.  For pregnant women, the threshold was 185% and for children, 235%.

That meant a family of four had to earn less than $15,000 per year to qualify.  Some states did not cover childless adults at all, though New Jersey did, and many states, including New Jersey, offered more generous coverage than federally required.

When the ACA was enacted in 2010, one of its chief mechanisms for making health care available to millions more Americans was to raise the income eligibility cap for Medicaid to 138% of the Poverty Level and require states to cover adults who had income up to that amount. Currently, that works out to $2,962 per month for a family of four ($35,544 annually), $1,437 per month for a single person ($17,244 annually) and $1,945 per month for a childless couple ($23,340 annually).

The ACA further provided that the federal government would pay the full cost of expansion for the first three years, after which the federal share would decline in stages, bottoming out at 90% by 2020.

The ACA was subjected to multiple court challenges and one of them,  National Federation of Independent Business v. Sebelius, made it to the U.S. Supreme Court. In June 2012, the Court narrowly upheld the constitutionality of the ACA’s individual mandate, but it found the Medicaid expansion aspect of the law unconstitutionally coercive in threatening states with complete loss of federal funding for Medicaid, if they did not comply.

As a result, the expansion was deemed optional, leaving the door open for state governments who opposed the ACA, chiefly led by Repubicans, to refuse expansion.

Despite the opportunity to obtain health care for needy citizens with federal money,  only 29 states plus the District of Columbia, initially chose to go along with expansion when it took effect on January 1, 2014. New Jersey was one of them, although its Governor, Chris Christie, a Republican, balked at setting up a state exchange for individual insurance plans under the ACA. (That mistake is in the process of being rectified as a result of legislation signed into law on June 28.) Other states that took advantage of Medicaid expansion from the get-go include California, Connecticut, Minnesota, New York, Ohio, Oregon and Vermont.

Since 2014, that number of expansion states has since grown to 37, with the addition of Indiana, Louisiana, Michigan, Montana, New Hampshire and Pennsylvania, along with Maine and Virginia, both of which implemented expansion only this past January.

That leaves just 14 hold-outs: Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming.

The NBER study focused on adults who were between the ages of 55-64 in 2014, using mortality figures, census data and more detailed information from the ongoing American Community Survey.

In the words of the study authors, this is what they found: “Our analysis shows that the ACA Medicaid expansion reduced mortality among the targeted group. Prior to the expansions, individuals in our sample residing in expansion and non-expansion states had very similar trends in both Medicaid coverage and mortality. At the time of the expansion, the trajectories of these two groups diverged significantly, with expansion state residents seeing increases in Medicaid coverage and decreases in the probability of being uninsured, and decreases in annual mortality rates.”

The difference between expansion and non-expansion states in the probability of mortality existed from year one (2014) but grew wider each year. To the authors, this quite logically suggested that “prolonged exposure to Medicaid results in increasing health improvements.”

In addition, based on supplemental data showing cause of death, they found no comparable evidence of a drop in deaths from external causes, such as car accidents, only from internal causes amenable to healthcare. They also saw no similar fall in mortality among those over 65, who werer old enough to qualify for Medicare and thus not likely to gain coverage through the Medicaid expansion.

And when the authors looked at individuals in higher income households, who were less likely to qualify for Medicaid, they saw a smaller decrease in mortality commensurate with the much smaller increase in Medicaid coverage among that group.

By highlighting the high cost of non-expansion–more than five times the death toll from the Sept. 11 attacks, to put things in perspective–the report should provide impetus for the holdout states to expand Medicaid.  

That battle is still playing out. On July 29, 2019, it was reported that CMS announced  it would no longer approve full funding for a partial Medicaid expansion by states that seek to do that, including Utah and North Carolina.

Utah, for example, is not counted among the 14 holdouts because its voters passed a ballot measure in November 2018 that required the state to expand Medicaid coverage to 138% of the Poverty Level beginning on April 1, 2019. But this past February, Utah Governor Gary Herbert, a Republican, signed legislation that would limit the expansion for adults only to those making up to 100% of Poverty Level, rather than 138%. Consequently, 40,000 fewer people would gain coverage. In addition, the Utah law would add a work requirement as a condition of eligibility, cap enrollment in expansion coverage, and  incorporate a per capita ceiling on federal reimbursement.

Similarly, voters in Maine approved expansion through a ballot initiative in November 2017, but then-Governor Paul LePage, a Republican,  delayed it. It was implemented via executive order by current Governor Janet Mills, a Democrat, in January of this year.

As the study authors point out, the low-income individuals who rely on Medicaid are especially vulnerable “given that they experience dramatically higher mortality rates and worse health outcomes.” And they are at higher risk of dying from several conditions that are believed to be amenable to drug therapy: diabetes; cardiovascular disease; and respiratory disease.

“Medicaid could play a crucial role in reducing these disparities if it improves access to effective medical care that beneficiaries would not otherwise receive, and recent research shows this is likely to be the case,” write the study authors. They also note that Medicaid coverage may also benefit health if it leads to earlier detection and treatment of life-threatening conditions such as cancer, as well as increasing the availability of medical procedures and hospital care.





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