Policymakers Cannot Deny What Medicaid Expansion Means to Survival

It is never easy to absorb unpleasant information.

And when I was a policymaker, if someone told me that my decisions were going to cost innocent people their lives, then I usually chalked it up either to hyper-sensationalism or hyperbole. 

After all, would passing a small increase in a business tax really force an employer to imperil workers by cutting corners on safety?  Would gun registration really leave a homeowner defenseless in the case of a break-in? Would cutting back welfare a few dollars actually result in a choice between eating or heating in the winter?

In most instances, it was hard to see the direct connection.

But the more I learned about health issues, the more I understood that there really were some decisions that were a matter of life and death.  These were the issues that taught me humility.  These were the issues that taught me that I needed to set aside my political ideology and embrace both theology and hard data whenever they stared me in the face together.

One of those issues was Medicaid. 

Back in the late 1970s, I saw Medicaid as a safety net program for seniors and people with developmental disabilities to help pay for skilled nursing or intermediate care.

And so when Ronald Reagan and, later, George Bush agreed to expand the program to cover children and families, I admit I was skeptical.  Wouldn’t it burden taxpayers who were already paying far more for Medicaid than they ever expected?  Wasn’t private insurance enough? And what would happen if we did not go along – would anyone die without the expansion?

That was always the billion dollar question – who dies without the help of government?

We knew that people caught in fires, victimized by criminals, or trapped by natural disasters died.  We also knew that those who couldn’t get into hospitals, who couldn’t get emergency services, and who were given substandard care in institutions also died as a result.  But we did not know how Medicaid fit into this.

Fortunately, we voted to expand Medicaid anyway, taking it mostly on faith that it was the humanitarian thing to do.  And now we know the result.  We saved a lot of lives, just as if we had disarmed potential killers or rescued people from fires burning out of control,

We do not have to assert this as a matter of faith anymore.  We also have compelling hard data.

I wrote about this in February 2013 in a column I provocatively entitled Failure to Expand Medicaid: Just another Death Penalty?   If you are interested, you can read the full column by clicking on the title, but the essential point was this: Based on a study published in the highly-respected New England Journal of Medicine, it did not take a rocket scientist to calculate that as many as 36,000 lives nationwide hung in the balance of the Medicaid expansion. 

It may not be hard for a policymaker to dismiss the results of a single study; I did it myself in my day.

But it is not quite so easy to dismiss two.  

And there was a second study, conducted by the prestigious RAND Corporation, published by the equally reputable Health Affairs in June of 2013.  I wrote about it in another column entitled Grim Numbers Result from Failure to Expand Medicaid.  By then, we could all come up with a first set of estimates of the numbers of people who would die in just those states that failed to expand Medicaid last year – up to 19,000.

But last year’s sessions were over by the time people saw the report.  And so they likely threw it into the bottom of the circular file and forgot about it.

But can similar evidence be denied a third time – much as Peter denied knowing Christ?

Health Affairs blog published a new report just days ago, entitled Opting Out of Medicaid Expansion: The Health and Financial Impacts.  It found that up to 17,000 lives still hang in the balance in states that have refused to expand Medicaid.

As Health News Florida pointed out: “More than 1,100 Floridians will die prematurely if the state Legislature continues to refuse to expand Medicaid.” As will more than 1,800 in Texas, 500 in Georgia, 400 in North Carolina, 350 in Pennsylvania, and 200 in Missouri, Alabama, Virginia, Louisiana, Tennessee, South Carolina, and Indiana.

Policymakers in those states – and others – can continue to vote against Medicaid expansion, but they had better be willing to embrace what they are doing.  They are sentencing innocent people to death, and they will own this forever.   

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Failure to Expand Medicaid: Just Another Death Penalty?

For many, the fight over whether or not to expand Medicaid is just about the money.  But they overlook the fact that the lives of more than 36,000 people may hang in the balance. 

That’s the conclusion that can be drawn from a study published last summer in the New England Journal of Medicine.  The study was entitled Mortality and Access to Care Among Adults After State Medicaid Expansions.  In it, the authors calculated the numbers of lives saved as a result of an earlier Medicaid expansion in three states.

The three states were Arizona, New York, and Maine.  And while none of these expansion populations matched exactly the expansion population in the Affordable Care Act, they were similar enough to suggest that we might see the same results in the ACA Medicaid expansion population.

The authors concluded that Medicaid expansions could save 19.6 lives for every 100,000 people between the ages of 20 and 64. 

There are over 185 million Americans between the ages of 20 and 64.  That comes to 36,301 lives saved.

These lives are more important than the money. 

These people have families and friends who care about them.  And while some would like to think they should be able to make it on their own, the truth is that they need our help.

Most elected officials seem to get this.  I don’t see why it should even be newsworthy that six Republican governors have now said they support the expansion.   They understand reality.

For example, Governor Jan Brewer of Arizona favors the ACA expansion.  Expansion will save her state money, and it could also save an estimated 723 lives.  For a pro-life governor, what’s not to like about that?

Arizona was the last state to embrace the original Medicaid program.  Perhaps the people of Arizona learned from that experience something that the rest of us take for granted – Medicaid makes a big difference in the lives of people in the state as a whole.

In the four most populous states alone, the numbers of lives hanging in the balance is in the thousands. 

California and New York are already moving forward with the expansion.  That’s good news for an estimated 6700 people, 4421 in California and 2325 in New York.  One of those California lives saved could be my son’s.

But in Texas and Florida, two states at the epicenter of the anti-expansion universe, over 5000 lives still hang in the balance – 2925 in Texas and 2162 in Florida.  The decisions of those state legislatures will have a profound effect on the lives of many other fathers’ and mothers’ sons and daughters.

But expansion means lives saved in every state.  North Carolina can save 1126, Connecticut 422, and Utah 304. 

The table I’ve created with the calculations for all the states is here.

Every study has its limitations, and this one is no exception. 

However, the authors openly acknowledged the limitations of their study when they published it.  They noted that other analyses of the data led to similar results.  By one alternate analysis, they found that for every 176 new adults covered by Medicaid, one death was prevented.

That doesn’t seem like many at first.  However, the ACA Medicaid expansion, if fully implemented by every state, will cover an estimated 15.1 million new adults.  By that measure the expansion would save even more lives – a total of 85,568 nationwide.

What about the money?

In March of last year, the Congressional Budget Office calculated the cost of a full Medicaid and SCHIP expansion to be roughly $103 billion per year.  (More recent CBO Medicaid cost estimates are lower because CBO assumes not all states will expand.)  That comes to $2.8 million per life saved. 

The state share of that cost would be about $198,000.

I’m sure that some might argue that we can’t afford $2.8 million per life – unless of course, the life is their own or their child’s.

But more objective researchers with no political agenda to promote have actually taken the time to calculate the economic value of a life.  It comes to $7 million or more, making the paltry $198,000 one of the best investments a state could make.

So the questions become first, how much are our lives worth to our states?  And second, is the failure to expand Medicaid just another death penalty – one that targets the sick and innocent?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/