Daaleman: Medicaid expansion and the health of North Carolinians
Gov. Pat McCrory recently signed off on a House committee measure that forgoes the expansion of Medicaid, the federal-state health insurance program for children, low-income parents, older adults and people with disabilities, under the Affordable Care Act.
Under the new federal law, nonelderly adults making less than 138 percent of the federal poverty level (about $31,000 for a family of four) would qualify, and there is understandable concern by the governor about the financial costs associated with expanding eligibility. Although the discussion leading up to this decision has focused on fiscal matters, such as the federal contribution to the program, job creation in the health sector and the shift from private to government insurance, there has been surprisingly little mention of how Medicaid expansion would impact the health of North Carolinians.
Over the past decade, several states have already expanded Medicaid eligibility in a manner comparable to what has been proposed in North Carolina. A recent study in the New England Journal of Medicine (NEJM) examined how such expansion would impact overall mortality or death rates, and the cost-associated barriers to health care, especially among lower income and minority populations.
The study looked at three states that have already expanded Medicaid eligibility – Arizona, Maine, and New York – and compared them with neighboring states that did not over a 10-year period. In those states that expanded Medicaid eligibility, there was a significant 6 percent reduction in all-cause mortality, when compared with states that did not have eligibility expansion.
For North Carolina, where Medicaid expansion would impact roughly 500,000 citizens, this corresponds to 2,840 deaths being prevented a year. And it’s important to note that the reduction in death rates would be expected to be greatest among working adults between the ages of 35 and 64 years, in minorities and for those residents residing in economically disadvantaged counties.
The study also showed that Medicaid expansion decreased the rates of delaying needed medical care due to cost reasons. This is an equally important finding since, according to the Centers for Disease Control and Prevention, uninsured adults are much more likely than insured adults to have delayed seeking or not received health care services due to cost.
The strong linkage between having insurance and better health was brought home to me in a patient I have been caring for since 2007. Dan (not his real name) works in construction and has had diabetes since he was a teenager, a condition that requires insulin and other medications, as well as regular surveillance of his eyes, cardiovascular and kidney functions. During the recent recession, Dan tried to keep working through a series of contracting jobs, none of which, unfortunately, provided health insurance.
I would see Dan infrequently and would refill his medicines and recommend needed services and consultation with my specialty colleagues for his diabetes, which was not well controlled. When asked, Dan would acknowledge that he needed this care, but since he wasn’t feeling bad and had a limited income, he would extend the duration of his prescriptions by skipping days and declined routine testing for his eyesight and kidney function, which are not uncommon practices for lower income patients. Unfortunately for Dan, his longstanding diabetes has recently worsened to the point of causing his kidneys to fail, and he is preparing to undergo dialysis. Dan is in his early 30s and the good news, I guess, is that since he has end-stage kidney disease, his health insurance will now be covered by Medicare.
McCrory has framed his decision against Medicaid expansion as one of cost, but this rationale does not take into consideration the overall health and economic value of extending the program’s eligibility to people like Dan. There is a strong precedent of North Carolina investing in the health of its citizens, most notably through the Good Health Plan, which was launched in the 1940s and was one of the most ambitious and successful programs of any state. Indeed, the words of the one of the plan’s proponents, J. Melville Broughton, governor of North Carolina from 1941-1945, still ring true today as they did nearly 70 years ago, “The ultimate purpose of this program should be that no person in North Carolina shall lack adequate hospital care or medical treatment by reason of poverty or low income.”
The health of North Carolinians deserves no less.
Dr. Timothy P. Daaleman is professor and vice chair of family medicine at the University of North Carolina at Chapel Hill.