EDUARDO PORTER: Making Medicaid tool for moral education may let some die

Posted January 17, 2018 5:00 a.m. EST
Updated January 17, 2018 7:16 a.m. EST


EDITOR'S NOTE: Eduardo Porter writes the Economic Scene column for The New York Times. Formerly he was a member of The Times’ editorial board.

Apparently the plan to Make America Great Again will let some Americans die.

Kentucky rushed last week to become the first of the nation’s 50 states to impose a work requirement on recipients of Medicaid. Under the state’s HEALTH plan, most able-bodied 19-to-64-year-olds — excluding the pregnant, the medically frail and some others — will have to work, get job training or perform community service for at least 20 hours a week to qualify for coverage.

They will have to pay for it, too — a premium starting at $1 per month for families living on up to one-quarter of the federal poverty line, or about $400 a month for a family of three.

The initiative is, of course, not about saving the state money by pushing poor people off the insurance rolls. It is providing moral education. In the words of Gov. Matt Bevin, the HEALTH plan will free Kentuckians from the “dead-end entitlement trap” and give them “a path forward and upward” so they can fend for themselves.

The plan is expected to reduce Medicaid spending by $2.4 billion over five years. Roughly half of the 350,000 able-bodied Medicaid beneficiaries in Kentucky currently do not meet the work requirements, by the government’s estimates, and could lose their benefits. Five years from now, the Bevin administration calculates, the change will have culled some 100,000 people from the rolls.

Kentucky won’t be the last. North Carolina, Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, Utah and Wisconsin have already submitted their own similar proposals. Barring legal challenges, the Trump administration is eager to let them do it. Millions of Americans stand at risk of losing their health care.  Many — the most fragile, the least great — could die as a result.

Bevin might care to glance south over the border. In 2005, Tennessee removed 170,000 people — almost one in 10 Medicaid beneficiaries in the state, mainly working-age adults without children — from its Medicaid program to save money. They didn’t do well.

One study found that childless adults in Tennessee — especially the least educated — started delaying or forgoing visits to the doctor. They reported suffering more days in bad health and incapacitated. And they recorded more visits to hospital emergency rooms, which must care for all comers, regardless of their ability to pay.

Delayed care can kill. Breast cancer is the second-leading cause of cancer death among women. One of eight American women will get it.  Detecting it early is critical.  Specifically, the five-year relative survival rate for localized breast cancer is 98.5 percent when detected early, but only 25 percent when detected at a distant stage.  Waiting for 60 days or longer to get treatment raises the risk of dying of breast cancer over five years by 85 percent.

Another study from Tennessee found that losing access to Medicaid led to delays in diagnosis, so more breast cancers were caught at a later stage. Women who lived in low-income ZIP codes were 3.3 percentage points more likely to be diagnosed with late-stage cancer, compared with women living in high-income ZIP codes.

“We are ready to show America how this can and will be done,” Bevin said. Kentucky’s approach to Medicaid draws from a well-worn playbook, one from which both Republicans and Democrats have drawn to trim the social safety net over the years.

Kentucky was an eager participant in the last big so-called entitlement reform, visited upon the nation’s poor just over two decades ago. Under that 1996 program directed at welfare benefits, the entitlement to federal assistance was replaced by a hodgepodge of programs managed by the states and financed by a fixed dollop of federal cash. Work requirements became the norm. And people got less help.

The number of families in poverty in Kentucky has budged little since then, declining to 116,000 from 132,000. But the number of families getting cash assistance has fallen by two-thirds. Today, the Temporary Assistance for Needy Families program covers only one of five poor families in the state.  For a single mother with two children, it provides $262 a month — a third less than it did two decades ago, adjusted for inflation.

Kentucky is hardly the stingiest state. In 15 states, antipoverty cash benefits reach fewer than 10 percent of the families with children in poverty. In all of them, the change was sold as a way to encourage poor Americans to get off their backsides, get a job and prosper on their own — free of the clutches of the welfare state.  Though it pushed many poor families into employment, it failed at mitigating their distress: rarely do such families’ breadwinners earn enough to move out of poverty.

The problem with the latest twist in Republicans’ effort to pare the social safety net is that removing the poor’s health insurance may not just make their life more difficult.

It might kill them.

It is well known by now that health insurance saves lives. A review of recent research in the Annals of Internal Medicine concluded that the odds of dying for non-elderly adults are between 3 percent and 41 percent higher for the uninsured than for the insured.

Work by Katherine Baicker, now at the University of Chicago, with Benjamin Sommers and Arnold Epstein at Harvard found that Medicaid expansions in the past significantly reduced mortality. The research “suggests that 176 additional adults would need to be covered by Medicaid in order to prevent one death per year.”

It doesn’t take a leap of imagination to figure out what might happen if 100,000 people were to lose their coverage.

As Lawrence H. Summers, once President Barack Obama’s top economic adviser, noted about the Republican tax cut passed in December, thousands would die if the tax bill were to cut the health insurance of 13 million people, as the nonpartisan Congressional Budget Office has estimated.

These would be mostly lower-income Americans. Maybe they would be people from Kentucky — the state with the most cancer deaths and the most preventable hospitalizations, 45th out of 50 in the incidence of diabetes and 47th in terms of heart disease.

Would their deaths cause America to be greater?