Health Informer - Medical News: Medicaid Expansion Could Cut Death Rate

Wednesday, July 25, 2012

Medicaid Expansion Could Cut Death Rate - MedPage Today

ByÂ David Pittman, Washington Correspondent, MedPage Today

Published: July 25, 2012

ReviewedÂ byÂ Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Action Points

Expanding Medicaid programs reduced mortality in low-income adults over a 10-year period, a study found.
Note that state Medicaid expansions to cover low-income adults were significantly associated with improved access to care and self-reported health.

Expanding Medicaid programs might actually reduce mortality in low-income adults, a three-state study found, calling into question states opting out of the Affordable Care Act's (ACA) Medicaid expansion in light of last month's landmark Supreme Court ruling.

All-cause mortality in New York, Maine, and Arizona dropped by 19.6 deaths per 100,000 adults -- a 6.1% decrease (P=0.001) -- over a 10-year period when Medicaid coverage was expanded, a study published online in the New England Journal of Medicine found.

Furthermore, Medicaid expansion decreased rates of care that was delayed because of cost by 2.9 percentage points (P=0.002) and increased rates of self-reported health status of "excellent" or "very good" by 2.2 percentage points (P=0.04), wrote Benjamin D. Sommers, MD, PhD, formerly of the Harvard School of Public Health and now with the Department of Health and Human Services (HHS) in Washington, and colleagues.

"Policymakers should be aware that major changes in Medicaid -- either expansions or reductions in coverage -- may have significant effects on the health of vulnerable populations," Sommers and colleagues wrote.

The study's results suggest that "the question of whether the states will expand Medicaid, therefore, is not just a question of politics; it is a question of life, health, and death," Timothy Jost, JD, of Washington and Lee University in Lexington, Va., and Sara Rosenbaum, JD, of George Washington University in Washington, wrote in an accompanying commentary.

The ACA required states to expand Medicaid to cover all non-elderly, low-income persons with incomes below 138% of the federal poverty level starting in 2014. States who chose not to expand their Medicaid programs were penalized financially under the law.

However, the Supreme Court deemed that expansion requirement unconstitutional, meaning that states could now choose to opt out without a penalty. Since then, Republican governors in Texas, South Carolina, Florida, Louisiana and elsewhere have vowed to refuse the Medicaid funding.

To see if expanding Medicaid coverage resulted in improved health status, Sommers and colleagues examined data from large health surveys for adults ages 20 to 64 who were observed 5 years before and after Medicaid programs were expanded in New York, Maine, and Arizona. Those states expanded to cover childless adults between 2000 and 2005. Neighboring states without major Medicaid expansion -- New Hampshire, Pennsylvania, Nevada, and New Mexico -- were used as controls.

The study found new enrollees were older, disproportionately minorities, and twice as likely to be in poor health as the general population, all suggesting higher mortality.

Results also were adjusted to account for economic measures that could have caused states to expand Medicaid when economies where thriving which could cause a spurious correlation between health and expansion.

Tim Sweeney, health policy director for the nonprofit think tank Georgia Budget and Policy Institute, told MedPage Today in an interview that the Sommers study confirms that access to health insurance makes people healthier. "It can't do anything but help in the perspective of helping states move forward in their decision making," Sweeney said.

The ACA includes coverage of 100% of the cost of expanded coverage for the first 3 years, dropping down to 90% by 2020. That federal backing allows participating states to cover thousands of low-income residents with little investment, and hospitals and doctors could see a drop in uncompensated care they provide.

"Resisting states effectively intensify the huge uncompensated care burden faced by their hospitals, deprive other healthcare industry players of important revenues, and keep their medically underserved communities from receiving an enormous economic infusion," the perspective stated.

States may try to find as much wiggle room as possible, Jost and Rosenbaum predicted, suggesting that states may press the HHS to allow them to cover newly eligible adults and not others. "The administration may be pressured to enter into negotiations with each state using its waiver authority," they said.

A July 10 letter from HHS Secretary Kathleen Sebelius stated the Supreme Court ruling was limited to newly eligible adults.

There are several limitations to the study, Sommers admitted. Mortality data couldn't be controlled for characteristics other than race, sex, or age. Also, the data were largely driven by New York, so results may not be generalizable to other states. Lastly, the nonrandomized design cannot control causality.

Even for think tanks like Sweeney's, it's hard to tell how many new patients doctors could treat because many already access care now without Medicaid, Sweeney said.

Sommers reported he had no conflicts of interest. One of his co-authors reported relationships with Eli Lilly, the Medicare Payment Advisory Commission (MedPAC), Strategy 1, Campbell Alliance, TIAA-CREF, and Geraon Lehman.

The editorialists reported they had no conflicts of interest.

Primary source: New England Journal of Medicine
Source reference:
Jost TS, et al "The Supreme Court and the future of Medicaid" N Eng J Med 2012; DOI:10.1056/NEJMp1208219.

Additional source: New England Journal of Medicine
Source reference:
Sommers BD, et al "Mortality and access to care among adults after state Medicaid expansions" N Eng J Med 2012; DOI:10.1056/NEJMsa1202099.

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