Does Failure To Expand Medicaid Kill People?

Who’s killing whom?

Writing in The New York Times the other day, Paul Krugman had this to say:

And while supposed ObamaCare horror stories keep on turning out to be false, it’s already quite easy to find examples of people who died because their states refused to expand Medicaid. According to one recent study, the death toll from Medicaid rejection is likely to run between 7,000 and 17,000 Americans each year.

Really? 17,000 deaths per year? This outrageous claim flies in the face of years of careful study by real economists — who have concluded that there is almost no relationship between health insurance and mortality in the general population. As we previously reported:

In independent empirical papers, Richard Kronick and David Card and his colleagues find little evidence that health insurance coverage significantly reduces mortality. Former Director of the Congressional Budget Office June O’Neill and her husband Dave also conclude that lack of insurance has little or no impact on mortality. See the discussion at this blog here, here and here.

So where does Krugman’s claim come from? Not from economists, it turns out, but from a Health Affairs blog post  by Sam Dickman, David Himmelstein, Danny McCormick and Steffie Woolhandler. And notably, they do not do what serious scholarly papers do — acknowledge the work of other scholars who have addressed this same topic.

Their numbers rely on surveys known to overestimate the uninsured and on results from papers with methodological problems that are both serious and widely known. Their claim that failing to expand Medicaid in conformance with ObamaCare dictates will kill somewhere between 7,115 and 17,104 people a year confuses ideological posturing with scholarship.

Knock, knock, knockin’ on heaven’s door

 The older studies concluding that being uninsured increases mortality tend to be of lower quality than those that find it has no discernable effect. Dickman et al. continue this tradition in selecting the research results underlying their methodology for calculating the upper and lower bounds for their death estimates.  The upper bound estimates depend upon the results in a 2012 paper by Sommers et al. which neglects the effects of HIV infection when comparing all-cause mortality in New York with that of other states. The lower bound estimates depend upon the results in a 2009 paper by Wilper et al. It assumed that people who were uninsured at the time they were interviewed remained uninsured a decade later and found that health insurance was so important that having it reduced an individual’s chance of dying by 40 percent.

The Sommers paper concludes that Medicaid expansion reduced unadjusted nonelderly all-cause mortality by 19.6 deaths per 100,000 from a baseline of 320 deaths per 100,000. It compared mortality in three states that expanded Medicaid coverage in the early 2000s (New York, Maine and Arizona) with mortality in four neighboring states (Pennsylvania, New Hampshire and Nevada plus New Mexico) that did not. New York accounted for about 45 percent of the sample population in the paper. The authors write that their results were “largely driven by” New York.

The time periods used for the comparison were the five years immediately before the first full year in which a state’s Medicaid expansion took effect, and the first five years after the expansion.

Aside from the usual problems inherent in the sort of ecologic modeling the Sommers paper is attempting, its results were likely influenced by the higher than normal 2001 mortality rate caused by the World Trade Center attack, and by New York’s extremely high rate of HIV infection.

It is easy to see the World Trade Center mortality bump in the red line of the graph on the right, which comes from page 1,029 of the Sommers paper. Year 0 is the year in which each state’s Medicaid expansion was first implemented. It is 2002 for New York and Arizona, and 2003 for Maine. Maine’s population makes up about 5 percent of the sample population and deaths each year.ha1

The expansion sample death rate rose sharply in the expansion states in year -1 to 0, or 2001, falling back to previous levels in year 0 to 1, or 2002. While it is true that mortality immediately declined the year the two populous states expanded Medicaid, the mortality rate looked good in 2002 only because terrorism had made it look so bad in 2001.

Using data from CDC Wonder and New York State vital statistics to estimate all-cause mortality for the nonelderly suggests that excluding the World Trade Center deaths would lower 2001 mortality for the expansion states from 326 per 100,000 to about 314 per 100,000. This would erase the bump in the graph. It would also erase part of the reduction in mortality seen after the Medicaid expansion in the “expansion states.”

The marked decline in the crude mortality rate in the expansion states also appears to reflect the fact that at a time when HIV infection was a leading cause of death for nonelderly adults, New York’s HIV death rate was one of the highest in the country. The introduction of antiretroviral therapies in 1995 reduced the HIV mortality rate from very high rates in the late 1990s to high, but steadily declining, rates in the Medicaid expansion period. ha2

As the second graph shows, New York’s HIV death rate continued to decline after Medicaid was expanded, a decline that lowered the overall mortality rate in the expansion states. The reduced death rates were likely caused by antiretroviral therapies rather than Medicaid expansion. In Pennsylvania, a state that did not expand Medicaid and which was used as the “control state” for New York, death rates from HIV fell from 1997 to 1998, but were relatively constant thereafter and likely had little effect on the overall mortality rate simply because Pennsylvania did not have as many HIV deaths as New York.

Unless further research takes these differences into account, the Sommers paper will remain unconvincing in its claim that Medicaid expansion in New York, Arizona and Maine reduced all-cause mortality rates. As a result, the upper bound deaths from failing to expand Medicaid that are asserted in the Dicks et al. blog post are not credible.

In addition, here is what Chris Conover has to say about the Sommers paper:

I can state with great confidence that the authors have grossly overestimated any mortality gains to be had from Medicaid expansion. The evidence that Medicaid even has a positive effect on adult mortality risk is far more thin than the Harvard/CUNY team has led you to believe.

The Wilper paper uses the same strategy as the 1993 paper by Franks, Clancy and Gold to estimate that people who self-reported that they were uninsured in 1988-94 were 40 percent more likely to have died 6 to 12 years later in 2000. It applies this result to all states and claims that a lack of health insurance is associated with as many as 44,789 deaths a year in the United States.

This conclusion is based on self-reported insurance status for nonelderly adults who participated in the 1988-1994 NHANES III study. After excluding all the individuals who were in the survey and were covered by government health insurance, they were left with 12,112 people. Of those, 9,004 satisfactorily completed the interview and health examination and could be identified as living or dead in 2000. The error rate in the living or dead attribution is unknown. Earlier calibration studies estimated that 4 percent of NHANES respondents may be incorrectly classified as dead in follow-up surveys.

The problems with the Wilper methodology have been extensively discussed. Two examples may be found on this blog here and here. First, people who were uninsured at the time they were interviewed do not necessarily remain that way. Second, as Wilper et al. point out, other work suggests that between 7 and 11 percent of those who report that they are uninsured actually have insurance. Third, it is well known that the uninsured population differs from the privately insured population in important ways that are likely to have significant influence on health but are not controlled for in the Wilper study. Fourth, there is a literature showing that deaths are inversely related to income, and that higher incomes are associated with improved mental and physical health. Because Medicaid expansions and ObamaCare are likely to reduce incomes, their effects on health are highly unlikely to be all that their advocates claim.

Chris Conover at Forbes concludes that people will not die in states that don’t expand Medicaid.

Comments (27)

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  1. Ken says:

    Good post. Himmelstein and Woolhandler are not scholars. They are advocates.

  2. Perry says:

    Prior to Medicaid expansion, the poor have always been able to access hospital care through EMTALA, ie,
    no hospital can turn away patients due to inability to pay.

    • Matthew says:

      Exactly. People haven’t lost the ability to seek medical attention if they don’t get Medicaid. They will always have the ability to receive care, while it may not be affordable care.

      • Bill B. says:

        The only way people would die from failure of Medicaid expansion is if for that person, dying outweighs the cost of seeking uninsured health care.

        • Matthew says:

          “…death toll from Medicaid rejection is likely to run between 7,000 and 17,000 Americans each year”

          I don’t think that many Americans would see the cost of uninsured health care to be higher than losing their lives.

  3. Thomas says:

    “Not from economists, it turns out, but from a Health Affairs blog post by Sam Dickman, David Himmelstein, Danny McCormick and Steffie Woolhandler.”

    I am disappointed that Krugman wouldn’t get a more appropriate source to back up his wild claims.

  4. Buddy says:

    This is just another scare tactic to convince more people that ObamaCare isn’t as flawed as it is and to influence the public that it was the solution to fixing our healthcare problem.

  5. Paul P says:

    That is the problem with the field of economics. Because it is the study of fields, many economists just find information that is willing to prove their point, not considering that the data there are using was proved wrong by different studies. True economists leave aside their partisanship when conducting research in order to reach valuable, new advances in the field.

  6. Fred Y says:

    Krugman is killing the economics field with his statements, exemplifying what can happen when your partisanship blinds your judgment.

  7. charlie bond says:

    Good morning John and Friends,
    People do not die for lack of money, but from lack of care. The correlation between resources and bad health is well known. That is why continuum-of-care-organizations (COCO’s) are so important. These organizations not only break down the barriers between providers to better coordinate care, but they reach out with volunteer and social services to attack the things we know contribute to bad outcomes and higher costs for people with fewer resources: food, housing, companionship–all these things correlate to outcomes and costs.
    This correlation underlies the work of Dr. Jeff Brenner in New Jersey and Dr. Rodney Hood in San Diego and is described in Guwande’s New Yorker article “Hot Spotters.” Rebecca Ohne has also mobilized volunteer college students in an organization called Health Leads, which she describes in the best TED talk I have seen.
    It is not that we have to cure all social ills to provide health care,but we do need to address those well known issues that directly affect health care costs and outcomes for people who are sick. Some of those issues are not medicine, operations or “treatment” per se. They are nonetheless the exercise of self-interested compassion, because if we can make folks healthier and less likely to use expensive sick care (as opposed to health care), it will save us money in the long run. So ultimately, this form of compassion is conservative, and common sense suggests it may be a better use of resources than expanding broken payment systems.
    Just a thought for the morning.
    Charlie Bond

    • Ruben S says:

      Completely agree with you. If we don’t treat each other with compassion it is impossible to make a significant betterment of society. Our society has grown so apathetic, that when people see someone dying on the street, we change sidewalks. People don’t die because they don’t have healthcare, people die because we stopped caring.

      • Greg Scandlen says:

        No, people die because of dysfunctional behaviors, whether we “care” or not. Even in the UK, lower income, less well educated people have much worse health status than others — even though all have the same coverage. The behaviors that make people poor also make them sick.

        • Devon Herrick says:

          There is a high degree of correlation between income, education, social status and health status. It’s not the insurance that directly improves health. It’s the associated behaviors that cause educated people to value health coverage. The same preferences and priorities that cause someone to jog, eat right, manage their cholesterol is probably the same belief system that causes them to want health coverage. More than 60% of medical conditions are a related to lifestyle behaviors. Merely enrolling someone in a health plan cannot replace healthy behaviors.

  8. Ruben S says:

    Looking only for papers that support your claims shows that the study is not serious and when looking for those papers that exaggerates findings, to prove a point reaffirms that the study is not useful at all.

  9. Ron says:

    I thought the “Oregon Experiment” of uninsured vs Medicaid was a real study that showed no difference in health status between the two groups. If there is no health status difference, how can there be a mortality difference?

    In addition, how many have died from the under treatment and mistreatment of Medicaid, a second class healthcare delivery system?

  10. Elena Siddall says:

    It’s like wondering what giraffes and apples have in common. Why not take a look at statistic dealing with the insured-1) private, 2) Medicaid, 3) Medicare and death while in treatment vs. the uninsured?

    With the Census Bureau getting into the ObamaCare act – I suggest that all Death Certificates indicate the insurance status of the deceased.

    • John R. Graham says:

      Thank you. I think that would actually be a bad idea, because it would perpetuate the notion that a person is born into a certain insurance status and it stays with him for decades.

      In fact, people migrate from one insurance status to another. Pre-Obamacare, a Medicaid dependent was about 50 percent likely to become insured by an employer plan next year. (Of course, the higher income Medicaid dependents were more likely to switch than the very poor.)

      This is one reason why the whole business of comparing the Medicaid population with the privately insured population is fraught with measurement challenges.

  11. Al Baun says:

    As always, my hat is off for Charlie Bond’s position; however, as for Ms. Gorman’s words “real economists — who have concluded that there is almost no relationship between health insurance and mortality in the general population” I find disturbing.

    Disregarding Paul Krugman, The Times, and Ms. Gorman’s opposing sources, one can easily deduce that if someone has reasonable access (via insurance) to free preventive services–which can identify and address chronic illnesses– there is a high probability that they may use those services.

    Here is a source which is difficult to argue with.

    •Chronic diseases cause 7 in 10 deaths each year in the United States.

    •About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.

    •More than 75% of health care costs are due to chronic conditions.

    Ms. Gorman, please let you words ‘do no harm’

  12. John R. Graham says:

    “… 4 percent of NHANES respondents may be incorrectly classified as dead in follow-up surveys.”

    Incorrectly classified as dead? Maybe they should have spoken louder into the phone!

  13. Dayana Osuna says:

    Paul is just a very sick puppy with tremendous bubbles and his think tank.

  14. Alieta Eck, MD says:

    In the University Hospital in Newark, NJ, people with no money and no insurance used to apply for “charity care.” If they fit the criteria, they got it. This gave them a year of free labs, radiology and hospital services. Local doctors caring for local patients in local hospitals got the job done. The hospital might recoup its losses from the state at the end of the year, depending on the quantity of charity care they gave.

    Now these same patients are being told they must sign up for Medicaid. Surgeons generally are not enrolled in Medicaid. Last week, several patients were scheduled for surgery under “charity care,” where the surgeon was offering his services for free.

    The “charity care” operations were cancelled, as the physicians still do not want to enroll in Medicaid. A part of the ACA that many are not aware of is the fact that the HOSPITAL cannot bill for Medicaid unless the physician is a Medicaid physician. So these patients were denied admission to the hospital.

    The fact that more people will suffer or even die under Medicaid than with no insurance is demonstrated here.

  15. Wanda J. Jones says:

    This is the right place for a reference to a new public health model of health and illness: it’s “social assets.” Two public health officers from Alameda County in California and in St Louis, compared their health statistics and their stats for crime, education, etc., and found that there was a direct correlation between health status and the whole set of social assets, from being in a two-parent home, to years of education, job stress, and so on. The main positive asset value came from education. Anthony Iton, MD, is the author from Alameda. I commend this to everyone who worries about health outcomes, as being covered by insurance does not show up as a main determining factor in health.

    I concur that most people can obtain health services in an emergency, but there are many people who do not present for care because they are afraid of being “known,” are embarrassed by the potential diagnosis, are afraid of death from certain diagnoses, or are prevented by a family member. So Social-cultural factors can be much more powerful than pure coverage.

    But this topic brings up another concern: the public as a whole is being under-served in being allowed to have a high level of “negative knowledge assets.” That is, they know things that are not so, listen to people like Krugman, and just don’t bother with health matters until they are sick. The health field appears content to argue arcane issues in professional blogs and journals, which the public never sees. Meanwhile, large health plans and provider organizations spend hundreds of millions on advertising their brand name, with no knowledge content at all. Those of us in any corner of public health should take on some of the job of reducing the “galloping ignorance factor” whenever we can.

    Remember that Obamacare was intended to be the stalking hose for single payer. The lazy thinkers among us will actually say: “If Obamacare fails, we should just go to single payer and everything will be much simpler.” (The same screw-ups will be running that, you dolts!) Terrifying.

    Happy Spring:

  16. Wanda J. Jones says:

    horse. Sorry.


  17. Bob Hertz says:

    Dr Eck raises a fascinating point.

    Namely, that the treatment of the poor is better under informal hospital charity than it is under Medicaid.

    implying that if the only goal of Medicaid to lessen death rates, then the best solution is no Medicaid at all.

    We are a long way from 1936, when Bessie Smith died in Alabama because several all-white hospitals refused to admit her during a life and death emergency.

    Five states have laws that virtually command hospitals to forgive part or all of the bills of uninsured persons who are poor.

    I would not mind seeing those laws expanded to all states, and expanded to 300% or so of poverty. But both of my little solutions are far cheaper than expanding Medicaid.

    • John R. Graham says:

      Let’s remember how these hospitals started: Usually in the 19th century founded by civic leaders of a certain religious denomination. That’s why we have Presbyterian, Methodist, Catholic, Adventist, and Jewish hospitals.

      They felt a duty to their communities and went ahead and executed their duties. They did not complain to government about “uncompensated care”. The whole point of the exercise was to deliver some proportion of uncompensated care!

      I suspect that those civic leaders look down from the next world upon today’s non-profit hospitals and shake their heads in lamentation at their current ethos. The idea that the federal government would fund the hospitals would abhor many of them, I suspect.

  18. Bob Hertz says:

    Those older civic leaders would be equally appalled at the way that hospitals must beat up on one class of patients in order to provide free care to another class.

    The budgets of our non-profit hospitals must surely exceed $400 billion a year.

    There is nowhere near enough dollars in religious charities to sustain such large enterprises.

    Government funding may in fact be the least evil solution.