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Cruel results of state Medicaid policy – 15,600 lives lost

July 24, 2019

Topics: Quote of the Day

By Sarah Miller, Sean Altekruse, Norman Johnson, and Laura R. Wherry
National Bureau of Economic Research, July 2019


We use large-scale federal survey data linked to administrative death records to investigate the relationship between Medicaid enrollment and mortality. Our analysis compares changes in mortality for near-elderly adults in states with and without Affordable Care Act Medicaid expansions. We identify adults most likely to benefit using survey information on socioeconomic and citizenship status, and public program participation. We find a 0.13 percentage point decline in annual mortality, a 9.3 percent reduction over the sample mean, associated with Medicaid expansion for this population. The effect is driven by a reduction in disease-related deaths and grows over time. We find no evidence of differential pre-treatment trends in outcomes and no effects among placebo groups.

Interpreting the Estimates

Our estimated change in mortality for our sample translates into sizeable gains in terms of the number of lives saved under Medicaid expansion. Since there are about 3.7 million individuals who meet our sample criteria living in expansion states, our results indicate that approximately 4,800 fewer deaths occurred per year among this population, or roughly 19,200 fewer deaths over the first four years alone. Or, put differently, as there are approximately 3 million individuals meeting this sample criteria in non-expansion states, failure to expand in these states likely resulted in 15,600 additional deaths over this four year period that could have been avoided if the states had opted to expand coverage.


There is robust evidence that Medicaid increases the use of health care, including types of care that are well-established as efficacious such as prescription drugs and screening and early detection of cancers that are responsive to treatment. Given this, it may seem obvious that Medicaid would improve objective measures of health. However, due to data constraints, this relationship has been difficult to demonstrate empirically, leading to widespread skepticism that Medicaid has any salutary effect on health whatsoever. Our paper overcomes documented data challenges by taking advantage of large- scare federal survey data that has been linked to administrative records on mortality. Using these data, we show that the Medicaid expansions substantially reduced mortality rates among those who stood to benefit the most.



By Don McCanne, M.D.

Health policy can be a matter of life or death.

The Affordable Care Act offered states the opportunity to expand their Medicaid programs that provided care to low-income families, with 100 percent federal funding for the first three years. Several states declined the offer. This NBER report shows that this decision “likely resulted in 15,600 additional deaths” over the first four years of the program. For the states that expanded their Medicaid programs, there were “roughly 19,200 fewer deaths over the first four years.”

The ubiquitous media reports over the years suggest that these decisions to reject Medicaid expansion were based on political ideology, largely without much mention made of the concerns for the health outcomes of the affected populations, except, of course, by the advocates of health care justice. The opponents of public policies for reforming health care object to the use of the term “cruel” to describe these decisions, but that does not seem to be an inappropriate term to describe politicians who use a signature on a document to commit acts of voluntary manslaughter. (Whether this use of “voluntary manslaughter” fits the legal definition seems to have little import when considering that thousands actually died unnecessarily.)

Obviously the importance of health policy decisions extend far beyond the Medicaid program. We know what policies would improve the functioning of our health care system for the benefit of all of us. Optimal policies begin with the financing infrastructure inherent in the design of the single payer model of Medicare for All. The dispute is not over optimal policy. Tragically, the dispute is over politics. Leaving the current financing system in place while merely adding a public option trades away crucial beneficial policies for mere political considerations. On the other side, repealing the Affordable Care Act while promising only a nebulous “something great” as a replacement doesn’t even make an attempt to initiate rational policy discussions.

It is about policy. We can get that right. So what do we do about the politics that is perpetuating this cruelty? If we fail in our politics we will have to put up with more suffering, hardship, and even death. Now that’s cruel.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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