Death by Poverty

Jason Steinke sits next to a photograph of his wife, Jenny, who died in September due to asthma complications, at their rental home in Idaho Falls on Thursday.

PAT SUTPHIN, POST REGISTER

One of the most dramatic moments of Tuesday’s hearing on Medicaid expansion was when Dr. Kenneth Krell of Idaho Falls accused the Idaho Legislature of being responsible for the deaths of 324 people a year, or almost 1,000 over the past three years, due to lawmakers’ failure to expand Medicaid.

“I would ask you to please stop the killing,” Krell said, drawing applause and cheers from the Medicaid expansion supporters in the overflow room and a rebuke from Senate Health and Welfare Chairman Lee Heider, R-Twin Falls, who said he would shut down the next speaker who disrespects the Senate.

Krell is the director of critical care at Eastern Idaho Regional Medical Center, and one of Krell’s patients, Jenny Steinke, is one of the documented examples of someone who, arguably, might be alive today with Medicaid expansion.

Steinke had asthma, and since neither she nor her husband made enough at their jobs to afford insurance she was treating herself with short-acting inhalers from a community clinic. One day, the inhalers stopped working and a neighbor brought her, suffocating, to the hospital. She stopped breathing in the truck.

Medical staff worked hard to revive her but she ended up brain dead from prolonged oxygen deprivation and had to be taken off life support. Steinke’s story was reported in the Idaho Falls Post Register in October and picked up by newspapers across the state.

But what is this number of 1,000 people dead from a lack of Medicaid expansion based on?

It’s an extrapolation from a 2012 study in the New England Journal of Medicine, comparing mortality rates in three states that expanded Medicaid — New York, Maine and Arizona — to the rates in Pennsylvania, Nevada, New Mexico and New Hampshire, which didn’t.

Researchers analyzed deaths among people aged 20 to 64 — people over 64 qualify for Medicare, and children qualify for Medicaid – — and, after controlling for demographic and economic factors, “estimated that the Medicaid expansions were associated with a decline of 6.1 percent in deaths, or about 2,840 per year for every 500,000 adults added,” according to the New York Times’ write up of the study results. The study found a drop in death rates in the states that expanded Medicaid and an increase in the ones that didn’t.

“I can’t tell you for sure that this is a cause-and-effect relationship,” that the Medicaid expansion caused fewer non-elderly adults to die, one of the researchers told the paper. “I can tell you we did everything we could to rule out alternative explanations.”

So, Krell’s estimate of 324 deaths a year in Idaho caused by a lack of Medicaid expansion comes from the study’s conclusion that deaths in states without Medicaid expansion are 19.7 per 100,000 people higher, then multiplying this by Idaho’s population.

At the time, some conservatives noted the limitations to the data. Again from the New York Times:

“Douglas Holtz-Eakin, president of the American Action Forum, a Republican-oriented group, said the study was ‘well done’ and ‘brings more evidence in about the benefit side’ of Medicaid, but he wondered if the results could be generalized. The three states studied voluntarily expanded their Medicaid programs, presumably confident they could pay for the expansion, and had enough doctors accepting Medicaid to treat additional beneficiaries. Other states may be less able to afford it, he said, and it is possible that ‘having a piece of paper that says you’re on Medicaid doesn’t do any good because they can’t see anybody.’”

On the other side, opponents of Medicaid expansion frequently cite a study comparing Medicaid recipients to people not on Medicaid in Oregon after that state expanded Medicaid. Idaho Freedom Foundation Vice President Fred Binrbaum, the only person to testify against Medicaid expansion on Tuesday, cited this study as evidence that Medicaid doesn’t improve health outcomes.

Since Oregon used a lottery system to select the recipients — they had almost 30,000 slots but closer to 90,000 applicants — researchers followed one group that got Medicaid and one that didn’t. More than 12,000 people were part of the study. It found an increase in use of preventive care and hospital visits among the now-insured, but the only statistically significant health improvement researchers was a drop in rates of depression. Categories such as blood pressure and cholesterol didn’t change much. There were, though, decreases on financial strain for those who were on Medicaid.

Conservatives said the study shows the Medicaid expansion doesn’t do much, since health outcomes for those on Medicaid are pretty close to those for the uninsured:

“There is no way to spin these results as anything but a rebuke to those who are pushing states to expand Medicaid,” Michael Cannon, director of health policy studies for the Cato Institute, wrote for Real Clear Politics at the time. “The Obama administration has been trying to convince states to throw more than a trillion additional taxpayer dollars at Medicaid by participating in the expansion, when the best-designed research available cannot find any evidence that it improves the physical health of enrollees. The OHIE even studied the most vulnerable part of the Medicaid-expansion population — those below 100 percent of the federal poverty level — yet still found no improvements in physical health.”

Not everyone agreed with that take, pointing to the increase use of preventive care and medical care in general, plus the decrease in financial strain on the poor and now-insured, shows its benefits:

“Obviously, simply ‘feeling’ healthier does not an argument for expanding Medicaid make,” Brian Fung wrote in The Atlantic. “But the drop in depression diagnoses is a promising outcome given the condition’s links to all manner of unpleasant health consequences. Taking greater steps to identify health problems before they happen has also been touted as a key requirement in keeping healthcare costs low over the long term. And improvements in financial security — including a 40 percent drop in the likelihood of having to take out a loan or leave other bills unpaid due to spending on healthcare — are a promising sign if the aim is to make healthcare more affordable.”

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