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.