The continued importance of Medicaid expansion

Last week, the United States received a terrible report card on health care. The Commonwealth Fund, a private foundation dedicated to improving health care, ranked the U.S. system dead last in a list of eleven economically comparable countries such as England and France. While the U.S. came in fifth in terms of quality of care, it ranked 11th for access, efficiency, equity, healthy living and cost. Two chief features distinguish U.S medical care from that of other countries: lack of universal access to basic services, and their much higher price tag. 

The Affordable Care Act was designed primarily to address the issue of access for 47 million uninsured Americans. It created subsidized insurance exchanges for those above the poverty line who were not receiving employer-based plans and expanded Medicaid, the government health care program for low-income families, to include those below 138 percent of the poverty level.

The health insurance marketplaces that the ACA created are, in fact, greatly increasing the number of people who are able to afford insurance. More than 8 million people have signed up for coverage, the White House reports. But while these numbers are promising, more needs to be done. Twenty-four states have not expanded Medicaid as planned, leaving 5.7 million of the most vulnerable people without coverage. Many of these states, such as Mississippi and Louisiana, have the highest poverty rates and the highest rates of death and disability from diseases such as stroke and diabetes. These states are exactly the places that need Medicaid expansion the most, with poverty-stricken patients already suffering an unconscionably high proportion of disease, which will only worsen without access to care.

As a doctor practicing in the high-poverty, minority community of Washington Heights in New York City, I see daily evidence of the role that access to primary care has in pulling people back from the brink of disaster. I am the only person most of my patients know personally who speaks English. For almost all of my patients I am also the only person who has a connection to the larger system who knows them as more than just a Social Security number. The medical treatment of these visits tends to have dramatic consequences, with undiagnosed and poorly treated conditions being discovered and often controlled with great relief of suffering. But these medical conditions are also often complex, exacerbated by stressors such as unstable housing, insecure sources of food and unemployment.

As their primary care doctor, I help my patients control chronic diseases such as high blood pressure and diabetes, and prevent devastating events such as heart attacks and strokes. These outcomes are catastrophic not only because they can kill but also because with modern medicine people now often survive them, but usually with debilitating disabilities. The lack of basic medical care that leads to these outcomes destroys lives, especially for those who fight the daily battle of poverty. 

Primary care not only improves physical health but also offers a lifeline to the larger system of care, such as mental health and social services. Likewise, access to primary care reduces poverty by decreasing out-of-pocket spending on health, encouraging preventive care and reducing the risk of bankruptcy from emergencies. In a recent study, Dr. Benjamin Sommers of the Harvard School of Public Health used a novel economic analysis to show that Medicaid kept at least 2.6 million people out of poverty in 2010, with the most profound effects for the elderly, disabled, children and racial and ethnic minorities. These benefits made Medicaid the third most effective anti-poverty program in the country. 

Access to care through Medicaid also saves lives. In the first well-designed study of its kind in The New England Journal of Medicine, Sommers also examined the effects of expanded Medicaid, pre-Obamacare, for three different states — New York, Maine and Arizona. The death rate in these states relative to states that did not expand Medicaid dropped by 6.1 percent over a seven-year period, with the greatest impact again on the elderly, minorities and the poor. Previous research has also shown a mortality benefit for infants and children under Medicaid expansions in the 1990s.

Political opponents of Medicaid expansion claim the program is ineffective and too costly for states that are already poor. Sommers’ work demonstrates that, on the contrary, Medicaid saves lives and reduces poverty for citizens. On the state level, the cost of the Medicaid expansion is being funded 100 percent by the federal government for the first two years, and then 90 percent after that. Residents of the 24 states that are not expanding the program are contributing to the expansion in other states through their federal taxes, but without receiving any benefits themselves. Furthermore, the ACA did not deal with the fact that in the U.S., prescriptions, procedures and medical care are much costlier than anywhere else; this continues to plague people with all forms of insurance. As a country, we have to focus on a solution for making medical care less expensive, rather than treating the people who are most likely to suffer the consequences of poverty and chronic disease as the scapegoats for our national problem.

If the current inequity between state Medicaid programs continues, 5.7 million poor people in this country — many of whom happen to belong to racial and ethnic minorities — will be reduced to a control group for a study whose results we can predict. The benefits of access to care through Medicaid will become obvious, as the poor in excluded states do not receive lifesaving medical attention and suffer the consequences, and the health disparities between the states that expanded and those that did not become wider and wider.

In the quiet moments I have with my patients in my office, the interventions I make seem small: comforting a grieving mother, starting a medicine for high blood pressure, writing a letter of advocacy for housing. But these episodes of personalized care have ripple effects. Not only does my patients’ immediate health improve but they also learn how to take care of themselves and to use preventive measures before new problems arise. The result: Catastrophes are prevented and lives are held together. The most rewarding part of my job is also the most intangible — never having to hear about terrible news because it did not happen.