In 2010, the newly passed Affordable Care Act – also referred to as Obamacare required that states increase Medicaid eligibility to provide coverage to millions of uninsured Americans. Nearly half of states refused to participate in Medicaid expansion after the Supreme Court made it optional. Today, close to 25% of states do not have expanded access to Medicaid, and Medicaid expansion is now at the forefront of a national debate on President Biden’s Build Back Better legislation.
The latest research published by the Keck School of Medicine of USC sheds new light on that debate. A study published in The Lancet Public Health shows that making Medicaid more accessible to more people lowers the number of deaths. The study suggests that expanding Medicaid could result in an overall reduction of 3.8 percent in adult deaths each year.
Utilizing national data to search for results on a population level, we looked at five federally-maintained registries covering states that have increased Medicaid access, as well as those that haven’t. We found that Medicaid expansion has an effect on mortality rates. The magnitude of the benefit is correlated to the expansion.
Brian P. Lee MD, MAS, is the principal researcher and assistant professor of clinical medicine at the Keck School of Medicine.
The study showed that between 32 expansion states and 17 states that did not expand, Medicaid expansion was associated with an average of 12 fewer deaths per 100,000 adult annually. These findings could have important implications for public policy when it comes to improving health outcomes and enhancing quality of care.
Clear benefits, mixed results
The optional Medicaid expansion was introduced in 2014. It added health insurance for 12 million Americans. Lee’s research analyzed data from 2014-2018, during which Lee kept track of data.
One of the most significant findings of the study is that all-cause mortality dropped was also linked with decreases in the number of those who were uninsured even in states that do not have Medicaid expansion. The results suggest that increasing the number of people with health insurance is the mechanism driving the decrease in mortality that is associated with Medicaid expansion.
While there were obvious benefits to expanding Medicaid but the results varied from state to the next.
“The reduction in mortality from all causes was primarily due to the proportion of women and non-Hispanic African residents in each state. Lee stated states that haven’t expanded Medicare have higher proportions of poor and Black residents. This means that they will be the most benefitted from expanding Medicaid.
Different illnesses also produced different results.
“We showed that Medicaid expansion led to lower deaths from respiratory and cardiovascular disease which is understandable having access to more special treatment and prescription drugs results in fewer deaths attributed to chronic illnesses,” Lee said. “At the same time, the results reveal that expanding Medicaid did not have an impact on cancer-, infection- or opioid-related deaths, which may not be as influenced by preventative treatment.”
Bridging the gaps
The data on deaths caused by complications from opioid use was not conclusive but Lee said it was one of the study’s most interesting findings.
“Certain states – like Delaware, New Hampshire and New Jersey – have actually witnessed an increase in the number of deaths due to opioids associated with Medicaid expansion. Some have speculated that more opioid-related deaths could be due to individuals having access to prescription pain medications. Our research supports this hypothesis. is one that should be investigated more thoroughly,” he said.
Lee believes there may be other influences.
Lee said that despite the fact that people with addiction disorders are able to access services, they may not receive the right treatment or in a timely fashion. “We know this from experience.” “So even after we’ve bridged the insurance gap – i.e., covering more people on Medicaid or other health plans – there could be services gaps that need to be addressed to maximize the mortality-related benefits.”
A controlled approach
Lee’s study was designed to take multiple aspects into account. Earlier data had indicated that both the uninsured rates and the mortality rate were already declining prior to Medicaid expansion in 2014. To account for this, Lee and his colleagues conducted a difference-in-differences analysis, controlling for previous trends as a way to establish the accuracy of their findings.
He added, “This allowed us assess the absolute difference between all-cause mortality and cause-specific death after Medicaid expansion.”
The results could be used to inform policy makers in the United States and in other countries who are considering changing the access to public health services.
“Continued Medicaid expansion may be an instrument for policymakers to tackle the ongoing disparities in wealth and race, providing a ladder to better health outcomes and social mobility for these marginalized populations,” Lee said.
Lee, B.P. Lee, B.P. Lee, B.P. et. (2021). Medicaid expansion and variation in mortality across the USA. A national observational cohort study. The Lancet Public Health. doi.org/10.1016/S2468-2667(21)00252-8.
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