Medicaid saves lives, Exhibit 1,863

Evidence that having health insurance coverage will, indirectly, lower mortality has existed for some time.  Early, robust evidence began with the Rand Health Insurance Experiment that indicated insurance could affect the precursors of mortality.  This has been bolstered by a host of other articles since:

• Health Insurance and Mortality: Evidence From a National Cohort
• Health Insurance and Mortality in US Adults
• The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?
• Health Insurance Coverage And Mortality Among The Near-Elderly
• Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals: a Cross-Sectional Study

More recently, evidence has been emerging that Medicaid coverage, specifically, has a positive impact upon mortality:

• Medicaid Expansion Linked to Lower Maternal Mortality Rates
• Medicaid Expansion Fills Gaps in Maternal Health Coverage Leading to Healthier Mothers and Babies
• Association of Medicaid Expansion With Cardiovascular Mortality

A recent article published in JAMA further examines this, finding Medicaid eligibility expansion is associated with a reduction in deaths from substance abuse.

So, in all, you can see where Medicaid, a program for those who are the most vulnerable, has been shown to be effective in many ways, including savings lives (women, children, and all).

Tell me, why aren't we expanding this again?

Canary in the Coal mine?

The Washington Post published a deep dive into a group, Remote Area Medical, providing a free medical clinic in rural Tennesee.  They follow the story of a couple, Lisa and Stevie, trying to navigate getting care for their myriad of issues. 

This truly is a story of two people left behind by the country they live in.  They can't find care due to a lack of providers (retiring or moving away),  a lack of insurance (due to not having a good job with benefits), and a lack of money to pay for it (due to not being able to work because of their health issues).  They grow increasingly poor, in poor health, and despondent in their situation.

So, they come to the clinic to seek some redress.  What this article doesn't say, is that Remote Area Medical was formed to provide care in third world countries.  They soon learned, unfortunately, that third world conditions existed right in their back yard.

And, it is certain to get worse for those on the margins.  In Tennessee alone:

"Tennessee has lost 14 percent of its rural physicians and 18 percent of its rural hospitals in the past decade, leaving an estimated 2.5 million residents with insufficient access to medical care. The federal government now estimates thata record 50 million rural Americans live in what it calls "health care shortage areas," where the number of hospitals, family doctors, surgeons and paramedics has declined to 20-year lows."

Hospital closures are accelerating - more than 100 have rural hospitals have closed since 2010.  Along with this, come provider shortages, allied health shortages (pharmacists, etc), and a downturn in the local economy. 

Those areas that are already on the brink will feel these pains the most - smaller, rural, underserved communities.  Communities like the one in Cleveland, TN, where Stevie and Lisa sought care. 

How long, though, will it be before these effects are felt in other communities?  Those that thought they were immune to such problems?  Communities that are one business closure away from a downturn that has ripple effects not yet understood?

Later, the Washington Post correctly diagnosed one of Tennessee's problems - Medicaid Expansion (or the lack thereof).  Their key point:

"The point is that much of the collapse of rural health care could have been avoided, and could be easily reversed if so many state governments hadn’t chosen to impose misery on their own rural constituents."

I do not think it is too alarmist to fear that what is happening in in these rural, underserved areas could spread further.   Let's not forget Lisa and Stevie.

Impact of SNAP benefits

SNAP (Supplemental Nutritional Assistance Program)  is one of many safety-net programs that provide assistance to those in need.  Currently, more than 40 million US residents receive SNAP benefits; this number is considerably higher than the low of 17 million in 2000, has accelerated rapidly after the 2008 recession. Participation has declined steadily since 2013, which can be expected as the economy and job markets recovered from the lows of the great recession.

This program, and others like it, have always been a target for many conservatives in the US.  Often, SNAP benefits are seen as a large entitlement that goes towards folks who abuse, misuse, or do not deserve such a benefit.  Examples do exist of such egregious behavior, but as evidence indicates, this type of fraud and abuse is rare.

Regardless, it is difficult to argue that SNAP is not effective - it does provide a way for households to gain access to food and can even lift these families out of poverty. There are also indicators that the spending on SNAP is an economic multiplier - that is, for every day spent on SNAP benefits, there is a return back to that community of $1.55 - $1.79 in additional activity, as well as additional employment in those (and other) communities.

Further, more recent evidence backs up these benefits, with a particular emphasis on rural areas.  This county-level analysis indicated that for every $10,000 in SNAP spending, 1 additional job was created in these communities (during the recession), and 0.4 jobs outside the recession.  This was seen as a vital part of the recovery of these areas, incomplete as is was.  These effects were also greater than what was seen in urban areas, highlighting how important this program is to a substantial portion of our country.

Medicaid Coverage & Employment

Medicaid has always been a lightning rod for controversy, with 2019 being no different.  There is currently a move towards basing Medicaid coverage on some sort of work requirement; this began in January of 2018 when CMS Administrator Seema Verma introduced announced they would consider demonstration programs to:

 "...to test programs through Medicaid demonstration projects under which work or participation in other community engagement activities – including skills training, education, job search, volunteering or caregiving – would be a condition for Medicaid eligibility for able-bodied, working-age adults."

This announcement was followed by fifteen states proposing demonstration programs with some sort of work or volunteer requirement.  These requirements varied in the qualifying activities, the number of hours worked needed and exempted populations.

Arkansas was the first to implement their program, in Juen 2018.  This program, according to their own reports, resulted in 18,000 losing their Medicaid coverage in 2018 due to the requirement.  This would not be a bad outcome if those who lost Medicaid coverage did so due to gains in employment that offered insurance coverage.  Evidence suggests, however, that fewer than 2,000 of those who lost coverage gained employment, indicating a continued gap in coverage for a vast majority.

Further complicating this issue is the recent court ruling striking down these work requirements in Arkansas and Kentucky.  Despite this, other programs are proceeding while the US DHHS appeals the ruling.  The Kentucky Governor has stated that without the work requirements, they may scale back their Medicaid expansion altogether, endangering coverage for up to 400,000 residents.

These efforts undermine the effects that Medicaid coverage may be able to achieve on employment.  A recent study indicates that single moms had a net gain in employment in states with Medicaid expansion.  The mechanism for this increase?

"Mothers can make more money while still keeping their Medicaid benefits (whereas a lower Medicaid eligibility might discourage them from working in order to maintain coverage) and they can afford to take a job with no or subpar health insurance because Medicaid is covering them."

Time will tell how Medicaid Expansion, work requirements, and various other factors interact to impact coverage and employment among these groups.  Based on what we have seen so far, however, it seems that expansions without caveat may be the most effective overall.

Hidden Euthanasia

You know that feeling you get when something is just not right? For me, I get a weird shivery feeling on the back of my neck, and an uneasy feeling in my gut. Kind of like the horse in “Young Frankenstein” when Frau Blucher is mentioned. There are a lot of reasons I get this feeling; and I am going to catch flack for this one, but one of the main triggers is mentioning “pro-life.” 

In this case, it is the term “pro-life” being used to mean “anti-abortion.” And that is the problem for me: what does it mean to be “pro-life” in this world? I look around at our world with different lenses - mom, grandmother, daughter, nurse, military wife, public health advocate, Christ-follower - all of which help me see the world in different focus. 

The recent story of Charlie Gard in the UK reminded me again of what “life” is for many people. So many people were concerned about whether a child is allowed to “live” without considering what his life was really like, or could be. My current professional position takes me into the homes of people who are dealing with mental illness, many elderly and poor. Many have dementia, or depression. Most struggle with hopelessness, and most try to fit that into their own spiritual beliefs.  And their family struggles as well, with feelings of guilt for being inadequate (or worse, wishing for quietus,) and overwhelming responsibility. I see elderly people every day who are alone, poor, struggling, isolated, and feeling useless. Their lenses tell them that the best part of their life is over. They see that they are no longer contributing to the world in the way the world values, so they have no worth.  No one cares what they think (unless they’re a politician). No one cares about what they have or don’t have (unless they’re rich and there’s an inheritance coming.)  Their family sees them as a burden, and they know it’s true. 

This is not the case in every culture though. The elderly used to be held in high esteem, and still are in many other cultures. They are cared for lovingly until their death by their family.  This is changing not only in America, but also in places like Europe and Japan. Why? Oh man, that’s a can of worms question. I like what Pope Francis said: 

Look, at this moment, I think our world civilization has gone beyond its limits, it has gone beyond its limits because it has made money into such a god that we are now faced with a philosophy and a practice which exclude the two ends of life that are most full of promise for peoples. They exclude the elderly, obviously. You could easily think there is a kind of hidden euthanasia, that is, we don’t take care of the elderly; but there is also a cultural euthanasia, because we don’t allow them to speak, we don’t allow them to act. 

MEETING WITH YOUNG PEOPLE FROM ARGENTINA, ADDRESS OF HOLY FATHER FRANCIS, Thursday, 25 July 2013

I didn’t include the whole quote, but this part, in particular, applies to the question I’ve been ruminating about: At what point do we say that being “pro-life” includes caring for our elderly? 

One of the questions I hear a lot is, “Why won’t God just take me? I’m ready to go to heaven and be with Jesus and ______ !“(insert the name/names of their loved ones.)  If the person saying this is elderly, frail, lonely, unable to afford medicine and food, living in a place not of their choosing, no longer producing anything our society considers useful - is it wrong for them to yearn for death? Many Christians will say, “No, it’s not wrong. Jesus says heaven will be awesome! But don’t do it, or you’re not being grateful for everything you have.” They will tell their loved ones to fight for their life (that is, their earthly life) and then leave them alone in that fight while they go to work/school/soccer/vacation. They will say they must be depressed, so they just need a pill to make them feel better. True, that does help sometimes. But in our beloved country, we elevate usefulness above being, so we do not see value in the lives of those who cannot produce. This is true not only for the elderly, but also people with chronic illnesses and mental health issues. 

How is this in line with what Jesus teaches about loving each other? I mean, that’s what being pro-life is all about, right? You believe God creates each person, and therefore no life should be destroyed. If the pope is correct, we are destroying life every day through what he calls “hidden euthanasia.” Oh I agree, I’ve heard many Christians denounce euthanasia, so I believe this does outrage them - when euthanasia is a deliberate action that ends a life. Heaven help the person who chooses to stop eating or drinking, or taking their medicine, so their life can end. That’s suicide, and they’re going to hell. So are the doctors who enable them to do such an evil thing. Right? 

I can tell you that many of these hopeless people think they’re already in hell. No one is helping them experience life to the fullest, as Jesus promised. They hear the discussions on Fox News about how the poor are a burden on our health care economy, and how people who need government assistance are lazy and just want a handout. They live on social security because their promised pension and insurance benefits evaporated when their company’s CEO tapped their pension fund to ensure their profits for the investors. Is this representative of a Christian culture who is all about being “pro life?” 

If you think you don’t know anyone who has experienced this kind of slow death, take a walk. I visited with your neighbor last week. She is a widow, alone, and hungry, and scared at night. She didn’t get to her doctor’s appointment because she didn’t have a ride. She’s in the “donut hole” for Medicare so she can’t afford her medicine. No one took her to the store to buy groceries (she has $16 in SNAP benefits for the month to use.) She never gets to church anymore, so her christian friends have stopped calling. She really just wants to be with Jesus. Would you notice if she left the world? If no one notices, and she dies alone, is that euthanasia?

Got that feeling again...

Unintended Consequences of Policy--LGBTQ Edition

This article surprised me in many ways (in a good way).

One key point that REALLY stuck with me:

"Among self-identified LGBT high school students, 29 percent reported a suicide attempt in the previous twelve months, compared to 6 percent of their peers. Implementation of same-sex marriage laws was associated with a 7 percent reduction in self-reported suicide attempts among high school students, with most of the reduction among those who identified themselves as members of sexual minority groups."

First of all, 29%! If you care about life, at all, this should shock you and spur you to some sort of action.

Secondly, a law passed that would not affect them for some time was associated (*note, not a direct causal relationship) with a reduced risk for suicide.

As with everything, nothing is purely black and white; there are many reasons to be for or against certain policies and positions. However, these data are important to understand as realize not everything is so simple, and these 'big' policy decisions do have an impact in unexpected ways.

What is at the root of the AHCA?

In early May, the House of Representatives passed the American Health Care Act (AHCA).  Most experts point out that this bill will not be good news for many currently covered by the ACA . While there is not a current CBOP projection for this version of the bill, the prior version was scored and indicated:
--24 million lost in coverage
--880 (later cut to 814) billion in cuts to Medicaid (resulting in a loss of coverage of 14 of the 24 million)


While the current iteration made some changes (e.g. more funding of high-risk pools), the consensus is that this will not be enough to improve coverage.  Also, it does not restore funding to Medicaid, which is certain to result in coverage losses (despite their assertions otherwise).

The Incidental Economist helpfully summarizes what I think is at the root of the AHCA--tax cuts for those with higher incomes.  They summarize a report from the Brookings Institution and the Urban Institute, which is summarized nicely in these two charts:

 
Notice anything?  Essentially, under the AHCA, those in the lower income brackets will see their incomes DECREASE, compared to a net INCREASE under the ACA.

Why this difference?  What is the driving philosophy behind reducing incomes of already low-income Americans in favor of increase incomes of the already well to do?

Rep. Mo Brooks from Alabama may have inadvertently told us why--folks who are sicker are so because of poor lifestyles, choices, or behaviors, and should pay more than healthy folks. Here is the money quote:

"And right now, those are the people who have done things the right way that are seeing their costs skyrocketing"

Others have chimed in with similar sentiments:
"That doesn't mean we should take care of the person who sits at home, eats poorly and gets diabetes." --Mick Mulvaney, WH Budget Chief

"Best to mandate nothing. Let the customer decide. A 60-year-old couple doesn’t need maternity coverage. Why should they be forced to pay for it? And I don’t know about you, but I don’t need lactation services."--Charles Krauthammer, Washington Post Columnist

While these are politically minded statements, it is not uncommon to hear similar sentiments in Chrisitan circles as well.  How many have expressed feelings of anxiety or depression to their Christian friends, only to be met with the verse from Philippians ("Don't  be anxious about anything...through prayer and petition...") or Psalms ("The righteous cry out, and the Lord hears them; he delivers them from all their troubles."

Articles like this from Charisma Magazine certainly do not help, clearly indicating that illness is due to a lack of faith and obedience.  It also takes little time to do a search for stories of people with chronic illnesses being chastised by their fellow believers for their 'lack of faith' (see here, for example).

The clear implication, from both camps, is that if you are poor, sick, or otherwise in a bad way, it is not only your fault, but your lack of effort (either through work or faith) are preventing you from pulling yourself out of it.  Never mind any structural issues that may be preventing you from doing so (i.e. lack of job opportunities, medical debt, barriers due to the conditions, etc. - another discussion for another day).

I think once you understand this underlying philosophy, that is both in conservative and Christian minds, you can better understand how certain policies are created and advocated for by these folks, despite their apparent harm.