Despite concern by some analysts that Medicaid is worse than no health care at all, the Oregon Health Study and others, including this one, suggest that Medicaid improves access to care and might even have a mortality benefit.
For individuals and families with low-incomes and few resources, Medicaid may be the only form of health insurance they have. Medicaid currently insures over 62 million people, and the Affordable Care Act will extend eligibility to millions more starting in 2014. Although many agree that the goal of health care reform is to ensure affordable access to high quality care for all Americans, there is not as much known as to Medicaid’s effect on adult health.
Oregon is currently conducting a randomized, controlled trial of Medicaid; preliminary results showed significant improvement in self-reported health during the first year but no significant mortality effects. Since the Supreme Court has left the decision to expand Medicaid under the ACA to the individual states, many governors are considering not expanding due to budget constraints. It is possible that strong evidence supporting saved lives and improved health may persuade some governors to accept the federal aid.
The primary outcome of this study was the impact of Medicaid expansion on annual county-level, all-cause mortality per 100,000 adult recipients in Arizona, New York, and Maine. Researchers used a differences-in-differences quasi experimental design that incorporated data from 1997-2002 (before expansion) and 2002-2007 (after expansion) and compared it to neighboring states without major Medicaid expansions similar in population and demographic characteristics to the three states with Medicaid expansions: New Hampshire (for Maine), Pennsylvania (for New York), and Nevada and New Mexico (for Arizona). There were 68,012 age, sex, race, year, and county-specific observations collected from the Compressed Mortality File of the Centers for Disease Control and Prevention. The data were stratified by age, sex, and race. Secondary endpoints included rates of Medicaid insurance coverage, inability to obtain care in the past year because of costs (data from the Behavioral Risk Factor Surveillance System), and self-reported “excellent” or “good” health (data from the Current Population Survey).
Medicaid expansions were associated with an adjusted decrease in all-cause mortality of 19.6 deaths for every 100,000 adults. This was a relative reduction of 6.1 percent (p=0.001). Mortality benefits were highest among older adults, nonwhites, and residents of poorer counties. Other findings included an increase of Medicaid coverage by 2.2 percentage points (relative increase of 24.7 percent, p=0.01), a decrease in uninsurance by 3.2 percentage points (relative decrease of 14.7 percent, p<0.001), and a decrease in the rates of delayed care because of costs by 2.9 percentage points (relative decrease of 21.3 percent, p=0.002).
There was also an increase in the rates of self-reported health status of “excellent” or “very good” by 2.2 percentage points (relative increase of 3.4 percent, p = 0.04). Increases in Medicaid coverage in the expansion states were concentrated among low-income adults, whereas reductions in uninsured rates were significant for both lower- and higher-income groups. Reductions in cost-related delays in care were significant for all subgroups.
Overall, state Medicaid expansions to cover low-income adults were significantly associated with reduced mortality during a 5-year follow-up period as well as improved coverage, access to care, and self-reported health. The mortality reductions were greatest among adults aged 35-64 years, minorities, and residents of poor counties.
One of the limitations of this study is that single-state analyses showed significant effects only in the largest state, New York. This suggests the statistical significance of the results were driven primarily by New York. Thus, these findings may not be generalizable to all states. Since the CDC does not release individual-level mortality data, researchers were unable to adjust for individual level characteristics other than age, sex, and race.
With the expansion of Medicaid to all adults earning less than or equal to 133 percent FPL, many of whom are members of vulnerable populations, the expansion of Medicaid may have significant benefits on their health. These findings should influence states’ decisions to expand their Medicaid programs under the ACA.
Oluseyi Ojeifo, MD and Alden Landry, MD, MPH
is a practicing Emergency Medicine Physician at Beth Israel Deaconess Medical Center, Boston, MA. In addition to his clinical roles, Dr Landry is also the Director of Outreach for the Office of Multicultural Affairs at the hospital.
is currently a Mongan Commonwealth Fund Fellow in Minority Health Policy.
The Mongan Commonwealth Fund Fellowship in Minority Health Policy is designed to prepare physicians for leadership roles in formulating and promoting health policies and practices that improve the access to high-quality care at the national, state, and /or local levels for the minority, disadvantaged, and most vulnerable populations. This post represents a collaboration between that fellowship and Policy Prescriptions® to promote health policy journal clubs that will educate participants on the concept of evidence-based health policy.