[NYAPRS Enews] Study: Medicaid Expansion May Lower Death Rates

[Harvey Rosenthal]

Medicaid Expansion May Lower Death Rates, Study Says


By Pam Belluck  New York Times  July 25, 2012


 


Into the maelstrom of debate over whether Medicaid
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto
pics/medicaid/index.html?inline=nyt-classifier>  should cover more
people comes a new study by Harvard
<http://topics.nytimes.com/top/reference/timestopics/organizations/h/har
vard_university/index.html?inline=nyt-org>  researchers who found that
when states expanded their Medicaid programs and gave more poor people
health insurance
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto
pics/health_insurance_and_managed_care/index.html?inline=nyt-classifier>
, fewer people died.

The study <http://www.nejm.org/doi/full/10.1056/NEJMsa1202099> ,
published online Wednesday in The New England Journal of Medicine
<http://topics.nytimes.com/top/reference/timestopics/organizations/n/new
_england_journal_of_medicine/index.html?inline=nyt-org> , comes as
states are deciding whether to expand Medicaid by 2014 under the
Affordable Care Act, the Obama administration's health care law
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto
pics/health_insurance_and_managed_care/health_care_reform/index.html?inl
ine=nyt-classifier> . The Supreme Court ruling on the law last month
effectively gave states the option of accepting or rejecting an
expansion of Medicaid that had been expected to add 17 million people to
the program's rolls.

Medicaid expansions are controversial, not just because they cost states
money, but also because some critics, primarily conservatives, contend
the program does not improve the health of recipients and may even be
associated with worse health. Attempts to research that issue have
encountered the vexing problem of how to compare people who sign up for
Medicaid with those who are eligible but remain uninsured. People who
choose to enroll may be sicker, or they may be healthier and simply be
more motivated to see doctors.

The New England Journal study reflects a recent effort by researchers to
get around that problem and allow policy makers to make "evidence-based
decisions," said Katherine Baicker, an investigator on the study who
served on former President George W. Bush's Council of Economic
Advisers.

"I think it's a very significant study in part because of the paucity of
studies that have really looked at health outcomes of insurance
coverage," said Karen Davis, the president of the Commonwealth Fund, a
nonpartisan research foundation. "Actual mortality studies are few and
far between. This is a well-done study: timely, adds to the evidence
base, and certainly should raise concern about the failure to expand
Medicaid coverage to people most at risk of not getting the care that
they need."

The study, conducted by researchers from Harvard's School of Public
Health, analyzed data from three states that had expanded their programs
in the last decade to cover a population not normally eligible for
Medicaid: low-income adults without children or disabilities. The new
law also expands coverage to a similar population nationally.

Researchers looked at mortality rates in those states - New York, Maine
and Arizona - five years before and after the Medicaid expansions, and
compared them with those in four neighboring states - Pennsylvania,
Nevada, New Mexico and New Hampshire - that did not put such expansions
in place.

The number of deaths for people age 20 to 64 - adults too young to be
considered elderly by the researchers - decreased in the three states
with expanded coverage by about 1,500 combined per year, after adjusting
for population growth in those states, said Dr. Benjamin D. Sommers, a
physician and an assistant professor of health policy and economics who
was an author of the study.

In the five years before the expansion, there were about 46,400 deaths
per year, while in the five years after the expansion, there were about
44,900 deaths per year. During the same period, death rates in the four
comparison states increased, said Dr. Sommers, who began a yearlong
stint as an adviser to the federal Department of Health and Human
Services after research for the study was completed, but before its
publication.

When researchers adjusted the data for economic factors like income and
unemployment rates and population characteristics like age, sex and
race, and then compared those numbers with neighboring states, they
estimated that the Medicaid expansions were associated with a decline of
6.1 percent in deaths, or about 2,840 per year for every 500,000 adults
added.

While the data included all deaths, not just deaths of Medicaid
recipients, the decline in mortality was greatest among nonwhites and
people living in poorer counties, groups most affected by expanded
Medicaid coverage.

"I can't tell you for sure that this is a cause-and-effect
relationship," that the Medicaid expansion caused fewer non-elderly
adults to die, Dr. Sommers said. "I can tell you we did everything we
could to rule out alternative explanations."

Several experts with varying views on the Affordable Care Act said the
study, which was completed long before the Supreme Court hearings on the
law, was conducted by highly qualified researchers who carefully
analyzed the available data. Still, they and the study's authors pointed
to limitations in the data, noting that the mortality figures represent
county-level statistics, not individual deaths.

"They are trying really hard with the data that they have available, but
at the end of the day it doesn't really compensate for the fact that you
don't have the data you want, which is individual mortality rates and
what happens to people with change in coverage over time," said Gail
Wilensky, a health economist who headed Medicare
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto
pics/medicare/index.html?inline=nyt-classifier>  and Medicaid during the
administration of the elder President George Bush. In addition, when the
researchers looked individually at each of the three states, the only
state with a statistically significant decline was in the largest state,
New York, and she questioned whether every state would have the same
experience.

Douglas Holtz-Eakin, president of the American Action Forum, a
Republican-oriented group, said the study was "well done" and "brings
more evidence in about the benefit side" of Medicaid, but he wondered if
the results could be generalized. The three states studied voluntarily
expanded their Medicaid programs, presumably confident they could pay
for the expansion, and had enough doctors accepting Medicaid to treat
additional beneficiaries. Other states may be less able to afford it, he
said, and it is possible that "having a piece of paper that says you're
on Medicaid doesn't do any good because they can't see anybody."

Nonetheless, experts said, the results support those of another Medicaid
study being conducted by some of the same researchers in Oregon. Oregon
expanded its Medicaid program in 2008, but, without money to cover
everyone at first, chose 10,000 people by lottery. Dr. Baicker and her
colleagues, comparing those who got Medicaid with those who did not,
have so far found that Medicaid recipients see doctors more often, and
report better health and better financial stability.

The New England Journal study, published online several weeks before the
print edition because of its relevance to the current debate, also found
that people added to Medicaid in the three states reported better health
and were less likely to delay getting care.

While the data did not describe specific causes of death, researchers
found declines in two broad categories of deaths - those caused by
disease and those caused by accidents, injuries and drug abuse
<http://health.nytimes.com/health/guides/specialtopic/drug-abuse/overvie
w.html?inline=nyt-classifier> , possibly suggesting that even accident
victims may get or seek more extensive care if they are insured.

"So often you hear, 'Oh well, poor people just shoot each other, and
that's why they have higher mortality rates,' " said Diane Rowland,
executive vice president of the Kaiser Family Foundation, a nonprofit
group. "In the midst of many claims about what Medicaid does and doesn't
do, it actually shows that it cannot only be beneficial for health, but
in preventing some of the premature deaths of the uninsured."

Janet M. Currie, director of the Center for Health and Well-Being at
Princeton, said the new study, combined with the Oregon research, should
help transform the Medicaid debate into one about dollars, rather than
over whether covering poor people improves health.

"This says, well there is benefit to giving people insurance," Dr.
Currie said. "Maybe you don't want to pay the cost, but you can't say
there's no benefit."

http://www.nytimes.com/2012/07/26/health/policy/medicaid-expansion-may-l
ower-death-rate-study-says.html?_r=2&pagewanted=all

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://kilakwa.net/pipermail/nyaprs_kilakwa.net/attachments/20120727/14222df2/attachment.html>