Medicaid Expansion May Lower Death Rates, Study Says

Into the maelstrom of debate over whether Medicaid should cover more people comes a new study by Harvard researchers who found that when states expanded their Medicaid programs and gave more poor people health insurance, fewer people died.

• The study, published online Wednesday in The New England Journal of Medicine, comes as states are deciding whether to expand Medicaid by 2014 under the Affordable Care Act, the Obama administration’s health care law. 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 Medicareand 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, 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.”