Medicaid scale-up could reduce death toll, study finds


In 2010, the new Affordable Care Act – also known as Obamacare – required states to expand Medicaid eligibility to cover millions of uninsured Americans. But when the Supreme Court made extending Medicaid optional for states, nearly half withdrew. Today, nearly a quarter of states still have not improved access to Medicaid, and the expansion of Medicaid is now at the center of a nationwide debate over President Biden’s Build Back Better legislation.

Newly published research from USC’s Keck School of Medicine sheds new light on this debate. According to a study in Lancet Public Health, making Medicaid accessible to more people reduces the number of deaths. The study shows that the expansion of Medicaid can lead to an overall decline of about 3.8% in adult deaths each year.

Using national data to search for population-level results, we analyzed five federally administered registries covering states that have increased access to Medicaid as well as those that have not. We found that the expansion of Medicaid exerts an influence on death rates – and the magnitude of the benefits correlated with the magnitude of the expansion. “

Brian P. Lee, MD, MAS, Principal Investigator, Assistant Professor of Clinical Medicine, Keck School of Medicine

The study found that among 32 expanding states and 17 non-expanding states, the expansion of Medicaid was associated with nearly 12 fewer deaths per 100,000 adults per year. The results could have important implications for public policies to improve health outcomes and optimize the quality of care.

Clear benefits, mixed results

Implementation of the optional Medicaid extension began in 2014 and provided health coverage to an additional 12 million Americans. Lee’s study tracked data over the first four years of expansion eligibility, from 2014 to 2018.

One of the most important findings of the study is that the reduction in all-cause mortality was associated with the state-level reduction in the uninsured population, even in states that did not expand Medicaid. . The results suggest that the increase in the number of people with health insurance is the mechanism behind the improvements in mortality associated with the expansion of Medicaid.

Although the study showed clear benefits from the expansion of Medicaid, they varied by condition and disease.

“The reduction in all-cause mortality was mostly associated with the number of women and non-Hispanic black residents in each state. States that chose not to expand Medicare have higher proportions of poor and black residents. so they may have the most to gain from embracing the expansion of Medicaid, ”Lee said.

Different diseases have also given different results.

“We have shown that the expansion of Medicaid results in fewer cardiovascular and respiratory deaths, which makes sense: better access to specialist care and prescription drugs likely means fewer chronic disease deaths,” Lee said. At the same time, the data shows that the expansion of Medicaid has not had an impact on deaths from cancer, infections or opioids, which may not be as influenced by preventive care.

Closing the Gaps

Data on deaths from complications of opioid use were preliminary, but Lee said it was one of the study’s more interesting findings.

“Some states – like Delaware, New Hampshire, and New Jersey – have actually seen an increase in opioid-related mortality associated with the expansion of Medicaid. Some people have speculated that access to prescription pain relievers can lead to more opioid-related deaths. Our study shows that this hypothesis is something that needs to be explored more definitively, ”he said.

However, Lee says there may be other influences at play as well.

“We know from experience that, even with access to services, patients with substance use disorders may not have access to the right or timely services,” said Lee. “So even after you have closed the insurance gap – that is, covering more people with Medicaid or other health plans – there are probably service gaps that need to be addressed in order to maximize the benefits. mortality benefits. “

A controlled approach

Lee’s study was designed to take several factors into consideration. Earlier data had indicated that the uninsured rate and death rate were already declining before Medicaid’s expansion in 2014. To account for this, Lee and colleagues conducted a difference-in-difference analysis, controlling for previous trends as a means of establishing the correctness of their conclusions.

“This allowed us to assess the absolute difference in all-cause and per-cause mortality after the expansion of Medicaid,” he said.

Ultimately, the findings can inform the work of policy makers at the national level and in countries considering changes in access to public health services.

“The continued expansion of Medicaid can be a tool for policymakers to address disparities in wealth and race, providing a ladder towards better health outcomes and social mobility for these underserved populations,” Lee said.


USC Keck School of Medicine

Journal reference:

Lee, BP, et al. (2021) Medicaid expansion and variability in mortality in the United States: a national observational cohort study. Lancet Public Health.

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