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While pundits assess the fallout of this week’s midterm elections, voters in both red and blue states delivered a decisive victory in favor of Medicaid expansion.
Three states voted via referendum to expand Medicaid. Two other states that previously voted for expansion flipped from Republican governors who blocked it to Democratic governors who have pledged to expand coverage.
New research we published last month indicates that for thousands of Americans with a serious medical condition, this election could mean the difference between life and death.
Under the Affordable Care Act, 32 states and Washington, D.C., have thus far expanded Medicaid, leading to coverage for more than 15 million low-income adults. On Tuesday, Idaho, Nebraska and Utah voted via ballot referenda to expand Medicaid, with as many as 300,000 residents in these states poised to gain coverage.
Meanwhile, Maine — the first state to pass this kind of referendum — has not yet expanded because outgoing Gov. Paul LePage defied the voters and a federal court judge by refusing to implement it. Newly elected Democratic Gov. Janet Mills has pledged to carry out Maine’s Medicaid expansion. And in Kansas, where the Republican governor vetoed an expansion bill in 2017, incoming Democratic Gov. Laura Kelly is a strong supporter of expansion.
As voters and policymakers weigh the merits of expanding Medicaid, it is important to consider evidence on the impact of Medicaid coverage. Before the Affordable Care Act, Medicaid was generally only available to low-income adults in specific categories of eligibility, such as being disabled, pregnant or parents with dependent children. The Medicaid expansion makes things much simpler: Any American with an income below 138 percent of the federal poverty level — roughly $35,000 for a family of four — can qualify.
Research, including ours, has demonstrated that the Medicaid expansion led to major increases in the number of people with insurance, improved access to care, increased use of preventive services and better self-rated health. Yet perhaps no other question has captured more attention from proponents and critics of the Affordable Care Act than whether the Medicaid expansion has saved lives.
Our calculations suggest that for every 17 individuals with end-stage kidney failure gaining Medicaid coverage, one life was saved each year.
Several studies that predate the Affordable Care Act used natural and/or randomized experiments to examine the consequences of Medicaid on health outcomes. The Oregon Health Insurance Experiment, a randomized trial, found that Medicaid improved mental health and self-reported physical health, but did not produce statistically significant two-year improvements in blood pressure, cholesterol and diabetes control. However, the study may not have included enough people with serious illness to detect changes in these outcomes.
Meanwhile, a larger, population-based study of three states that expanded Medicaid coverage in the early 2000s found significant reductions in mortality in the five years following expansions. Whether these studies generalize to the Affordable Care Act and to other states remains unclear.
In a nationwide study just published in the Journal of American Medical Association, we offer some of the first evidence about the influence of the Affordable Care Act’s Medicaid expansion on mortality. We examined changes in death rates among people with kidney failure requiring dialysis, a group with mortality rates that are six to eight times greater than the rate in the general population.
Although most of the nearly 500,000 Americans that receive regular dialysis are eligible for Medicare coverage, for those under age 65, there is typically a three-month waiting period after starting dialysis before coverage begins. Because of this, 20 percent of patients younger than age 65 with kidney failure lacked coverage at the time of starting dialysis.
These uninsured patients generally receive lower-quality care before starting dialysis: They’re less likely to have seen a kidney specialist, they’re more likely to receive dialysis through a high-risk dialysis catheter, and they’re often in worse health. Many of these patients are unable to work and thus have no health insurance. This is precisely the type of poor health care access that the Medicaid expansion was designed to address.
What did we find? In expansion states, death rates for patients starting dialysis fell by roughly 10 percent, without any change in non-expansion states. We also found that more of these patients had health insurance, and the quality of care for these patients improved after expansion. Overall, our calculations suggest that for every 17 individuals with end-stage kidney failure gaining Medicaid coverage, one life was saved each year.
Our study joins dozens of others, including a new government report last month, demonstrating the positive impact of Medicaid expansion on low-income Americans. While some state officials worry about the costs of coverage expansion, the federal government pays for 90 percent of the Affordable Care Act’s Medicaid expansion, and research indicates that expansion has not negatively affected state budgets thus far.
Furthermore, economic analysis reveals that Medicaid expansion is cost-effective, an investment with a better health return than many other policy changes. Overall, our study shows that the health effects of insurance coverage are likely to be concentrated among individuals with serious chronic illnesses, like those with kidney failure.
As we assess the meaning of the midterm elections, politics will be the heavy focus. But for thousands of Americans with chronic conditions who will now gain health insurance through the Medicaid expansion, something much larger was at stake on Nov. 6 — and voters just sent them a lifeline.
Dr. Amal Trivedi is an associate professor at the Brown University School of Public Health. Dr. Benjamin Sommers is an associate professor of health policy and economics at the Harvard T.H. Chan School of Public Health and a primary care physician at Brigham & Women’s Hospital.
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