The Senate version of Trumpcare makes devastating cuts to the Medicaid program for low-income Americans. Many Republican supporters of the bill are responding to this issue by simply denying the cuts exist.
A more intellectually honest argument is advanced by Avik Roy, a conservative health care expert, in the Washington Post. In an editorial published Monday, Roy acknowledges Medicaid is cut, but argues that having Medicaid coverage is no better than being uninsured.
The Senate bill repeals Obamacare’s Medicaid expansion — an expansion that has trapped more than 12 million people in a program that researchers have shown has health outcomes no better than being uninsured. In its stead, the Senate bill offers low-income Americans robust tax credits to buy affordable private health insurance, just as those formerly enrolled in Obamacare’s exchanges will be able to.
Roy’s argument is based on a single study in Oregon. That study, which tracked about 10,000 Oregonians, found no statistically significant mortality impact between people with Medicaid coverage and people without it.
But there are a number of problems with the Oregon study that call into question Roy’s conclusion that Medicaid coverage is no better than not having any insurance coverage at all.
First, the study only followed up with subjects after two years. This is a problem because it “may take years for important effects of insurance coverage — such as increased use of primary and preventive care, or treatment for lifethreatening conditions such as cancer, HIV–AIDS, or liver or kidney disease — to manifest in reduced mortality, given that mortality changes in the other studies increased over time,” according to several researchers writing in the New England Journal of Medicine (NEJM) who reviewed multiple studies on Medicaid conducted over the past decade.
Second, as Mother Jones’ Kevin Drum notes, research into mortality is further complicated by the fact that the average age of a Medicaid recipient is only 38. That means, even in a study of 10,000 people, you’d only expect 20 or so per year to die — a very small sample size.
Monday morning on MSNBC, Sen. Al Franken (D-MN) countered Roy’s argument. He noted that the tax cuts that Trumpcare would deliver to the richest 400 taxpayers would pay for 750,000 people to be on Medicaid. Franken didn’t rely on a single study but cited the more comprehensive analysis of recent research on Medicaid published in NEJM. These researchers found that for every 750,000 people who lose Medicaid coverage, 1,000 to 2,000 people would die.
Franken actually understates the case. The NEJM cited a recent study estimating that Medicaid expansion has saved one life for every 239 to 319 people covered. That means enrolling 750,000 people in Medicaid could actually save 2,300 to 3,100 lives.
This also makes intuitive sense. When people have life-threatening illnesses, they need treatment and Medicaid gives them access to treatment. Without insurance, underlying health issues go untreated and can eventually be fatal.
There are also other benefits to health coverage besides avoiding death. It can, and does, improve quality of life. In fact, the same Oregon study that Roy uses to prove Medicaid is worthless did report improvements in a variety of health outcomes that impact people’s quality of life.
The Oregon study found significantly improved outcomes on a variety of issues — “depression, self-reported health, decrease in pain” — that “are themselves predictive of reduced mortality over a 5- to 10-year period.”
Roy’s argument also assumes that those who are kicked off of Medicaid would be able to afford coverage under the Trumpcare exchanges. This population, however, is near the poverty line. Although some may be able to pay a small premium, Trumpcare only requires insurance coverage to pay for 58 percent of costs. That means very low-income Americans, who currently are covered under Medicaid, would be expected to pay thousands of dollars in out-of-pocket costs — money they do not have.