Edward N. Squire Jr.: Failure to expand Medicaid leads to unconscionable deaths

May 7, 2014 

On April 9, Rob Christensen wrote “Whose side is God on?” underscoring the controversy about Medicaid’s expansion. Christensen cited Tim Phillips, president of Americans for Prosperity, opposing expansion. Phillips said that providing health insurance for the poor may actually “hurt the poor” and that it’s “immoral to dump” millions of Americans, our “fellow citizens,” into a program where they will “die sooner.” In defense of these grand assertions, he cited a study in which 13 percent more Medicaid patients died post-operatively than did patients in an uninsured comparison group. The mortality risk (compared with privately insured patients) was 1.97 for those with Medicaid and 1.74 for uninsured patients. That appears to have been the basis for the 13 percent figure and his preposterous generalization.

In addition, it is impossible to know just how sick these patients were pre-operatively. Moreover, Phillips seems unaware of the limitations of retrospective, observational studies as he remains fixated on this flimsy statistic as being revelatory of cause and effect. No knowledgeable researcher would dare say causality existed here – not without better studies and stronger evidence. Undeterred, Phillips blithely adheres to this outrageous claim that Medicaid patients may “die sooner” unless they become uninsured. Medicaid has plenty of problems, but this isn’t one of them.

How does the cited study stack up against two others (Baicker 2013 and Sommers 2012)? No surprise; they refute Phillips’ premise – a premise pertinent to 319,000 North Carolinians who would have been eligible for Medicaid had it been expanded here. Baicker studied 12,299 uninsured patients who were randomized (6,387 to Medicaid; 5,842 uninsured). The most significant, disease-related finding was a decline in the prevalence rate of depression, which dropped from 30 percent to 21 percent. In North Carolina, that would mean that every two years there would be 8,613 fewer cases of depression. How is conferring better mental health a way of “hurting the poor”?

Sommers studied seven states with a median mortality rate of 332 deaths per 100,000 people per year. He found that the three that had expanded Medicaid saw their mortality rate decline by 19.5 deaths per 100,000 per year – a reduction of 6 percent. How is extending lifespan connected with “dying sooner”?

These accumulating deaths will remain the unconscionable consequence of Republican intransigence. Without expanding Medicaid, needless death and suffering will continue. Phillips is simply wrong. Moreover, this intransigence shows no sign of abating. Given this persistent and profound resistance, these politicians can’t be expected to reverse themselves and begin to protect and preserve lives rather than presiding over preventable deaths. Depression hurts; people kill themselves to end the pain. Over two years in North Carolina, Medicaid’s expansion could have prevented 8,000 cases of depression and close to 2,000 deaths per year. Please don’t let it continue.

Edward N. Squire Jr., M.D.

Seven Lakes

The length limit was waived to permit a fuller response to the column.

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