The cost of not expanding Medicaid in Fla.? Nearly 2,800 deaths, a new report estimates

Former Gov. Rick Scott and Republican lawmakers' decision not to expand Medicaid under the Affordable Care Act is likely costing lives, according to new research on mortality rates for older adults who would have benefited from an expansion of the program.

A report by the Center on Budget and Policy Priorities released last week said states that expanded Medicaid showed significant reductions in death rates for older adults who fell into the income brackets that allowed them to gain the coverage. The report cited research estimating that, between 2014 and 2017, some 19,200 people who gained access in expansion states would have otherwise died.

But Florida is on the opposite end of that equation. According to the report's estimates, Florida likely suffered the second-highest total of deaths in that time period _ 2,776 _ attributed to not expanding Medicaid, trailing only Texas, which has an estimated 2,920 deaths. The CBBP report used a data analysis by the National Bureau of Economic Research.

To arrive at those numbers, researchers joined two sprawling data sets for what they said was a first-of-its-kind national study, adding new metrics to the debate on Medicaid expansion. Alison Yager, director of policy advocacy for the Miami-based Florida Health Justice Project, said the results were not surprising to anyone who has studied the "coverage gap" where an estimated 850,000 Floridians reside _ those who earn too much to receive Medicaid, but not enough to qualify for subsidies to buy a plan through the federal marketplace.

"What the report shows for the first time is the scale of the impact of that access and just how many lives are truly saved or lost because of the ability to connect to care and maintain that connection to care, particularly for people who have chronic conditions," Yager said.

The data analysis builds on existing research showing that access to Medicaid increases the use of medication to control chronic conditions, such as heart disease and diabetes, and boosts screenings and early detection of cancers that are responsive to treatment. In the NBER analysis, researchers were able to show a corresponding drop in mortality for those populations in Medicaid expansion states.

Sarah Miller, a researcher from the University of Michigan who co-authored the NBER analysis, said the research was motivated by "tremendous inequality in health by income" in the United States.

Miller said that a man at the top of the income distribution bracket who makes it to age 40 can expect to live 15 years longer than someone at the low end of that bracket.

"That's a huge discrepancy on the basis of income," Miller said.

The data analysis used Social Security Administration records to hone in on lower-income people who would fall under an expanded Medicaid program. Previous studies had been limited because researchers relied on death records that didn't have information on income.

"Before, there were just pieces of evidence that people found less convincing," Miller said. "Now we can say, when we look at low-income people, we find this effect."

Expanding Medicaid in Florida _ among 14 states that still have not broadened the program _ has been a nonstarter, particularly since 2015, when Scott reversed course on his temporary endorsement of Medicaid expansion and the Florida Legislature deadlocked on the proposal.

A bill to expand Medicaid has been filed in the Florida Legislature again this year, but its chances are slim, if not nonexistent.

"We will continue to maintain it as a large, broad-scale, big-term issue that we believe should be heard," said Rep. Nick Duran, D-Miami, a ranking member on several healthcare committees who sponsored the expansion bill during the 2019 legislative session. "Will that be heard on this sort of year? I don't think so. But nevertheless we think it's important for us to formalize it and put it as a bill."

The proposed bill resembles a compromise that the state of Virginia reached on Medicaid expansion, where legislators agreed to expand eligibility for the program in exchange for imposing work requirements on those who fall under the program.

"I think it's sort of an arbiter to come to the table and say, I know some of you are interested in work requirements for Medicaid recipients," Duran said. "Well, here's a model where we can at least start a... conversation on it."

Florida's bill, in the heavily Republican Legislature, did not receive a single hearing last spring. Next year's legislative session looks equally unlikely to host a discussion about expanding Medicaid.

"The chances [of expansion] are as likely as a foot of snow in Miami," said Sen. Aaron Bean, R-Fernandina Beach, who chairs the Senate's healthcare budget committee. "We had that debate a few years ago and we've moved on."

"You can get a study to say anything," he added, of the CBPP report.

Activists are trying to put a citizen initiative to expand Medicaid on the ballot in 2022, after an effort to add it to next year's ballot failed to gather enough signatures and donations.

And Republican lawmakers have been working to further contract the government healthcare program. They recently shortened the time period Medicaid can retroactively pay for hospital bills and are again weighing work requirements for people on the program. They have also criticized the costs of a Medicaid program for people with disabilities, which operates under a flexible federal waiver that gives the state more leeway on how to spend funds.

Other states have successfully passed work requirements and policies like retroactive pay for hospital bills. But those states that have obtained federal permission for those changes have also expanded Medicaid coverage under the Affordable Care Act.

Duran, the Miami Democrat, said studies like CBPP's reflect the larger impact of the Affordable Care Act.

"I do think this does save lives," Duran said of expanding Medicaid, pointing to the ability to connect with a primary care provider and identify long-standing health conditions. "What Medicaid expansion does is provide us with what is much needed funding to expand our program."

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