When the Affordable Care Act (ACA) passed in 2010, it included a provision to expand Medicaid eligibility to adults in families with incomes under 138% of the federal poverty line. Since the Medicaid expansion went into effect in 2014, research comparing expansion and nonexpansion states has linked expanded Medicaid access to better health outcomes. Additionally, some studies suggest that gaining Medicaid coverage is associated with a decline in medical debt, a reduction in personal bankruptcies, improved credit scores, and less reliance on predatory lending practices. Now the authors of a new working paper, published by the National Bureau of Economic Research (NBER), suggest another benefit: “substantially reduced mortality rates” among older adults with low incomes in the expansion states.

For the NBER study, researchers at the University of Michigan; University of California, Los Angeles; National Institutes of Health; and US Census Bureau combined demographic data from the American Community Survey with mortality information from the Social Security Administration for Americans with low incomes nearing Medicare age. Because the US Supreme Court ruled in 2012 that states could opt out of the Medicaid expansion, the researchers were able to study the differences between residents in expansion states and nonexpansion states. (As of 2019, 14 states have not expanded Medicaid.)

Not surprisingly, the states that expanded Medicaid had higher rates of health coverage. But the researchers also found that mortality rates in those states dropped, “saving 19,200 lives over four years. Had all 50 states expanded the program, 15,600 further deaths would have been averted,” Annie Lowrey reported in the Atlantic.

“The 22 mostly red states that refused to accept expansion starting in 2014 caused 15,600 unnecessary deaths among their residents,” Michael Hiltzik wrote in the Los Angeles Times.

Lead author Sarah Miller, PhD, assistant professor of business economics and public policy at the University of Michigan, told Vox’s Tara Golshan that the results of the preliminary study are actually conservative. “It’s very likely that younger adults were affected too, or people that were high income in our data but could have lost a job,” Miller said.

Progress Still Needs to Be Made

California was among the first states to expand its Medicaid program, Medi-Cal. Public polling shows that residents have very positive views of the program. A statewide poll conducted by CHCF and KFF (Kaiser Family Foundation) found that 70% of Californians have a favorable view of Medi-Cal, and 91% say that Medi-Cal is important for California. Nearly 60% of Californians say Medi-Cal is important to them and their families personally.

Additionally, a KFF Health Tracking Poll conducted at the end of 2018 found that about 75% of the public have a favorable view of the ACA’s Medicaid expansion. Among those living in nonexpansion states, 59% would like to see their state expand Medicaid.

There has been some progress. In the 2018 midterm elections, voters in historically conservative Idaho, Nebraska, and Utah passed ballot measures to expand Medicaid in their states. However, Golshan reported that “despite the mandate from voters, Republican lawmakers in those states have been trying to roll back Medicaid eligibility.”

The remaining 14 states that have not expanded Medicaid are Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. According to KFF’s State Health Facts, nearly two-thirds of those states are in the top 20 worst states for mortality rates.

The authors of the new NBER study concluded that their results “present consistent evidence of a decrease in all-cause mortality among low socioeconomic status, older adults under the ACA Medicaid expansions.” With the stakes so high, will those 14 states continue to hold out on expanding access to coverage?

Have you read any interesting research about the Medicaid expansion? Tweet at me with #EssentialCoverage or email me.

Xenia Shih Bion

Xenia Shih Bion is a communications officer at CHCF, where she helps to lead communications around the foundation’s work to create health equity. She is the founding author of the “Essential Coverage” column in The CHCF Blog. Read More

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