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'Live free and die?' The sad state of U.S. life expectancy
Just before Christmas, federal health officials confirmed life expectancy in America had dropped for a nearly unprecedented second year in a row – down to 76 years. While countries all over the world saw life expectancy rebound during the second year of the pandemic after the arrival of vaccines, the U.S. did not.
Then, last week, more bad news: Maternal mortality in the U.S. reached a high in 2021. Also, a paper in the Journal of the American Medical Association found rising mortality rates among U.S. children and adolescents.
"This is the first time in my career that I've ever seen [an increase in pediatric mortality] – it's always been declining in the United States for as long as I can remember," says the JAMA paper's lead author Steven Woolf, director emeritus of the Center on Society and Health at Virginia Commonwealth University. "Now, it's increasing at a magnitude that has not occurred at least for half a century."
Across the lifespan, and across every demographic group, Americans die at younger ages than their counterparts in other wealthy nations.
How could this happen? In a country that prides itself on scientific excellence and innovation, and spends an incredible amount of money on health care, the population keeps dying at younger and younger ages.
An unheard alarm
One group of people are not surprised at all: Woolf and the other researchers involved in a landmark, 400-page study ten years ago with a name that says it all: "Shorter Lives, Poorer Health." The research by a panel convened by the National Academy of Sciences and funded by the National Institutes of Health compared U.S. health and death with other developed countries. The results showed – convincingly – that the U.S. was stalling on health advances in the population while other countries raced ahead.
The authors tried to sound an alarm, but found few in the public or government or private sectors were willing to listen. In the years since, the trends have worsened. American life expectancy is lower than that of Cuba, Lebanon, and Czechia.
Ten years later, here's a look back at what that eye-popping study found, and why the researchers involved believe it's not too late to turn the trends around.
Beyond bad habits
Americans are used to hearing about how their poor diets and sedentary lifestyles make their health bad. It can seem easy to brush that off as another scold about eating more vegetables and getting more exercise. But the picture painted in the "Shorter Lives" report could shock even those who feel like they know the story.
"American children are less likely to live to age 5 than children in other high-income countries," the authors write on the second page. It goes on: "Even Americans with healthy behaviors, for example, those who are not obese or do not smoke, appear to have higher disease rates than their peers in other countries."
The researchers catalog what they call the "U.S. health disadvantage" – the fact that living in America is worse for your health and makes you more likely to die younger than if you lived in another rich country like the U.K., Switzerland or Japan.
"We went into this with an open mind as to why it is that the U.S. had a shorter life expectancy than people in other countries," says Woolf, who chaired the committee that produced the report. After looking across different age and racial and economic and geographic groups, he says, "what we found was that this problem existed in almost every category we looked at."
That's why, says Eileen Crimmins, professor of gerontology at the University of Southern California who was also on the panel that produced the report, they made a deliberate choice to focus on the health of the U.S. population as a whole.
"That was a decision – not to emphasize the differences in our population, because there is data that actually shows that even the top proportion of the U.S. population does worse than the top proportion of other populations," she explains. "We were trying to just say – look, this is an American problem."
Digging into the 'why'
The researchers were charged with documenting how Americans have more diseases and die younger and to explore the reasons why.
"We were very systematic and thorough about how we thought about this," says Woolf. The panel looked at American life and death in terms of the public health and medical care system, individual behaviors like diet and tobacco use, social factors like poverty and inequality, the physical environment, and public policies and values. "In every one of those five buckets, we found problems that distinguish the United States from other countries."
Yes, Americans eat more calories and lack universal access to health care. But there's also higher child poverty, racial segregation, social isolation, and more. Even the way cities are designed makes access to good food more difficult.
"Everybody has a pet thing they worry about and say, 'it's oral health' or 'it's suicides' – everyone has something that they're legitimately interested in and want to see more attention to," says John Haaga, who was the director of the Division of Behavioral and Social Research at the National Institute on Aging at NIH, before he retired. "The great value of an exercise like this one was to step back and say, 'OK, all of these things are going on, but which of them best account for these long-term population level trends that we're seeing?' "
The answer is varied. A big part of the difference between life and death in the U.S. and its peer countries is people dying or being killed before age 50. The "Shorter Lives" report specifically points to factors like teen pregnancy, drug overdoses, HIV, fatal car crashes, injuries, and violence.
"Two years difference in life expectancy probably comes from the fact that firearms are so available in the United States," Crimmins says. "There's the opioid epidemic, which is clearly ours – that was our drug companies and other countries didn't have that because those drugs were more controlled. Some of the difference comes from the fact that we are more likely to drive more miles. We have more cars," and ultimately, more fatal crashes.
"When we were doing it, we were joking we should call it 'Live free and die,' based on the New Hampshire slogan, ['Live free or die']," Crimmins says. "The National Academy of Sciences said, 'That's outrageous, that's too provocative.' "
There are some things Americans get right, according to the "Shorter Lives" report: "The United States has higher survival after age 75 than do peer countries, and it has higher rates of cancer screening and survival, better control of blood pressure and cholesterol levels, lower stroke mortality, lower rates of current smoking, and higher average household income." But those achievements, it's clear, aren't enough to offset the other problems that befall many Americans at younger ages.
All of this costs the country tremendously. Not only do families lose loved ones too soon, but having a sicker population costs the country as much as $100 billion every year in extra health care costs.
"Behind the statistics detailed in this report are the faces of young people – infants, children, and adolescents – who are unwell and dying early because conditions in this country are not as favorable as those in other countries," the paper's authors wrote.
Little action, despite the stakes
"Shorter Lives" is filled with recommended next steps for the government, especially the NIH, which has a budget of more than $40 billion annually to conduct research to improve Americans' health.
The NIH should undertake a "thorough examination of the policies and approaches that countries with better health outcomes have found useful and that may have application, with adaptations, in the United States," the authors wrote.
In other words: let's figure out what they are doing that works in other places, and do it over here.
Dr. Ravi Sawhney, who helped conceive of and launch the "Shorter Lives" study at NIH before he left the agency, had high hopes that the report would make a mark. "I really thought that when the results came out, they would be so obvious that people would say: Let's finally do this," he says.
Ten years on, how much of the detailed action plan has been done?
"To be brief, very little of that happened," Woolf says. At the time, he says, NIH officials didn't seem very interested in raising awareness about the panel's findings or in following up on its proposed research agenda. "There was some media coverage at the time that the report rolled out, but NIH was not involved in trying to promote awareness about the report."
Crimmins agrees. "There was a little bit more research, but there wasn't any policy reaction," she says. "I thought there might be, because it's embarrassing, but it just tends to be ignored." Those who are interested in this issue, she notes, tend to be those invested in "marvelous things they think are going to delay aging," even though people older than 75 are the only age group in the country that already does comparatively well.
Haaga, the former NIH division director, also thinks the response at the agency was lacking. "Not nearly enough has been done, given the stakes and given what we could learn," he says.
In response to NPR's request for comment for this story, NIH pointed to a subsequent panel on midlife mortality, several initiatives the agency has undertaken on disparities between subgroups within the U.S., and a recent paper funded by NIH that looked again at international life expectancy.
Outgoing NIH Director Francis Collins told NPR in 2021 that it bothered him that there hadn't been more gains to American life expectancy during his tenure. In his view, the success of NIH in achieving scientific breakthroughs hadn't translated to more gains because of problems in society that the research agency had little power to change.
Woolf calls it a misconception to assume that America's great scientific minds and medical discoveries translate to progress for the health of the population. "We are actually very innovative in making these kinds of breakthroughs, but we do very poorly in providing them to our population," he says.
'We can't touch everything'
Department of Health and Human Services Secretary Xavier Becerra answered NPR's question at a press conference earlier this month about work the agency was doing to address lagging life expectancy by mentioning COVID-19 and vaccine hesitancy, along with mental health issues and gun violence.
"There's so many things that we're doing," Becerra said. "We can't touch everything. We can't touch state laws that allow an individual to buy an assault weapon and then kill so many people. We can only come in afterwards."
CDC Director Rochelle Walensky responded by listing some of the agency's work on mental health and vaccines, and acting NIH director Larry Tabak pointed to research on health disparities.
HHS did not answer a follow up question about whether the agency has considered a national commission or similar effort to address American life expectancy and poor health.
Sawhney thinks the federal government should try harder to fix the problems documented in the "Shorter Lives" report. He doesn't think lack of public awareness is the problem. "I really think that most Americans know that Americans are more overweight and obese and that we have higher rates of disease and live shorter lives than other countries," he says, "It's just the NIH and the CDC that don't want to take the responsibility for that failure or to do anything about it."
Crimmins says, in her experience, lawmakers and federal health officials don't like talking about how the U.S. is lagging behind other countries.
"I convened a meeting in Washington with the National Center for Health Statistics [part of CDC] about increasing healthy life expectancy," she recalls. "It was a relatively small meeting, but we brought experts from Canada." An official at the time gave what she calls a "typical" response, saying: "Oh, we can't have anything but an American solution to these issues – we can't listen to other countries."
"International studies are not the flavor of the month – they never will be," says Haaga. "The problem with foreign countries is that they're not in someone's congressional district."
It's more than a missed opportunity, says Woolf. It's a tragedy.
"If you add up the excess deaths that have occurred in the United States because of this unfolding problem, it dwarfs what happened during COVID-19, as horrible as COVID-19 was," Woolf says. "We've lost many more Americans cumulatively because of this longer systemic issue. And if the systemic issue is unaddressed, it will continue to claim lives going forward."
Small victories are possible
Taking stock of the many ways in which Americans are sicker and die younger can be overwhelming, says Haaga. "It's such a long list, that might partly be why the issue doesn't grab people," he says. "They just go, 'Oh, my gosh, that's depressing, what's on the other channel?' But there's a lot of things that could be done, and small victories are victories."
According to the "Shorter Lives" report, "the important point about the U.S. health disadvantage is not that the United States is losing a competition with other countries, but that Americans are dying and suffering at rates that are demonstrably unnecessary."
Rather than feel overwhelmed at the immensity of the problems, Sawhney suggests, the focus should instead be on the fact that every other rich country has been able to figure out how to help people live longer, healthier lives. That means that Americans could do it too, he says.
He believes that the changes might not be as hard as some policymakers and health officials seem to think. "You look at these healthier countries, they're free countries – England, France, Italy – they're not banning delicious foods. They're not chaining people to treadmills," he says. "Americans love to travel to Europe, to Australia, to Canada to enjoy their foods and their lifestyles, and so the idea that we might say, 'Hey, maybe we could bring some of those lifestyles back' – I don't think people are going to go up in arms that we're taking away their freedoms."
Getting policy ideas from other countries is just an obvious move, Woolf adds. "If a martian came down to earth and saw this situation, it would be very intuitive that you [would] look at other countries that have been able to solve this problem and apply the lessons learned," he says.
In historical research he's been doing, "I found that there are dozens and dozens of countries on almost every continent of the world that have outperformed the United States for 50 years," he says. "It's worth taking a look at what they've done and Americanizing it – you don't have to take it right off the shelf."
Some of the policies he's identified as helpful include universal, better coordinated health care, strong health and safety protections, broad access to education, and more investments to help kids get off to a healthy start. These policies are "paying off for them," he says, and could for Americans, too.
Opinion A fiscally responsible government cannot keep its hands off Medicare
by The Editorial Board - Washington Post - March 24, 2023
Medicare is a successful component of the American social safety net. As of September, it covered 65.1 million people, 85 percent of them elderly. (The remainder were certain disabled workers and people with amyotrophic lateral scerlosis, commonly known as Lou Gehrig’s disease, or end-stage renal disease.)
It is also expensive: During fiscal 2022, the program accounted for $710 billion in federal spending, which was 11.4 percent of the $6.2 trillion total, according to the Congressional Budget Office. By 2028, the Medicare trust fund, which pays for hospitals, skilled nursing facilities and hospices, and is financed by payroll taxes, is expected to be exhausted. No rational approach to fiscal sustainability could wall off so many of the dollars that Washington spends every year. And yet that is what a de facto bipartisan consensus in Washington has effectively done.
This has to change. To be sure, President Biden proposed, in his 2024 budget, changes that would keep Medicare solvent for 25 years. He would accomplish this by adding more drug price negotiations (on top of the ones in last year’s Inflation Reduction Act) and raising a tax on the investment income of people who earn more than $400,000 a year. The president deserves credit at least for discussing the topic, but his plan is mostly political messaging rather than a serious approach to the issue. It places the entire burden of ensuring Medicare solvency on unpopular drug companies and high-income earners, implying — incorrectly — that structural reforms are unnecessary. Such changes could be carried out with relatively modest sacrifice from beneficiaries, in return for which all Americans would enjoy the security of a program built to last.
Containing costs for Medicare Advantage
Containing costs for Medicare Advantage, the alternative to “traditional” fee-for-service Medicare that now covers roughly half of all beneficiaries, is probably the most important step the president and Congress could take. Under Medicare Advantage, private health insurance companies provide managed-care coverage to Medicare-eligible patients in return for a per capita payment from the government. Many enrollees prefer Medicare Advantage plans because they can cover dental and vision needs, which regular Medicare does not.
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But the program costs more per beneficiary than traditional Medicare — 4 percent more, according to the latest government data. This is in part the perverse result of upward rate adjustments the government awards insurers to cover patients with higher “risk scores,” which incentivize Medicare Advantage companies to maximize each client’s reported ailments (known as “upcoding”). These adjustments, in turn, are made to rates that companies and the government negotiate relative to a predetermined baseline. Reducing that so-called benchmark by 10 percent would save the taxpayers a whopping $392 billion over 10 years, according to the CBO.
Would this force companies to trim some of the extras they provide? Perhaps, but it would also give them an incentive to innovate and be more efficient, reshaping plans based on what patients find truly essential. As the CBO points out, “additional payments to Medicare Advantage plans are allocated in part to additional benefits for Medicare Advantage enrollees and in part to plans’ administrative costs and profits.”
Eliminating payment discrepancies
Medicare pays more for services performed on an outpatient basis at hospitals than it does for the same services done at physicians’ offices or ambulatory surgical centers. This makes no sense and creates an incentive for hospitals to buy up independent doctors’ offices that they then relabel as hospital facilities. Eliminating this discrepancy could save $141 billion over 10 years. Equally irrational are the different co-pays and deductibles traditional Medicare assesses for doctor visits and hospital stays. Replacing that system with uniform cost-sharing rates and an annual out-of-pocket cap would save $27 billion over 10 years.
Distributing grants differently
Medicare helps teaching hospitals to pay the costs of training new doctors, directly — as compensation for residents — and indirectly. On the whole, this is a worthy use of the program’s funds, but in recent years expenses have been growing much faster than inflation. The current formula for allocating the money is complex and, according to a 2021 report by the Medicare Payment Advisory Commission (MedPAC), inexact relative to how hospitals actually treat patients. The CBO estimates that a new graduate medical education grant program, indexed to inflation, would save $68.2 billion over 10 years.
Reducing Medicare’s reimbursement rate for uncollectible hospital bills
A large chunk of hospitals’ unpaid bills — so-called bad debt — is now covered by the government. Reducing the government’s share from the current 65 percent to 25 percent would save $45.7 billion over 10 years. The hospitals would have to absorb the rest.
With these reforms in place, it would be more justifiable to extract additional tax revenue from wealthy investors. Specifically, closing the loophole that currently protects profits of so-called pass-through businesses, such as limited partnerships, from the 3.8 percent Medicare tax on net investment income would raise $249 billion over 10 years, mostly from high-income households.
A plan with these elements would make Medicare a much more sustainable program and provide its trust fund with an even longer lease on life than Mr. Biden’s proposal would. It can only do so, however, because it calls for sacrifice from powerful groups — doctors, hospitals, insurance companies. Their self-interest, plus the genuine, understandable fears of many seniors, presents a difficult political challenge. And yet it has to be overcome if this vital federal program, and the government as a whole, is to remain financially viable for future generations.
https://www.washingtonpost.com/opinions/2023/03/23/medicare-reform-fiscal-sustainability/
RALEIGH, N.C. (AP) — A Medicaid expansion deal in North Carolina received final legislative approval on Thursday, capping a decade of debate over whether the closely politically divided state should accept the federal government’s coverage for hundreds of thousands of low-income adults.
North Carolina is among states with Republican leaders that are considering expanding Medicaid after years of steadfast opposition. Voters in South Dakota approved expansion in a referendum in November. And in Alabama, advocates are urging lawmakers to take advantage of federal incentives to expand Medicaid in order to provide health insurance to more working people.
When Democratic Gov. Roy Cooper, a longtime expansion advocate, signs the bill, it should leave 10 states in the U.S. that haven’t adopted expansion. North Carolina has 2.9 million enrollees in traditional Medicaid coverage. Advocates have estimated that expansion could help 600,000 adults.
“Medicaid Expansion is a once in a generation investment that will make all North Carolina families healthier while strengthening our economy, and I look forward to signing this legislation soon,” Cooper tweeted.
There’s no set start date in the final bill for expansion under the legislation, but it still comes with one caveat: It can’t happen until after a state budget is approved. This usually happens in the early summer. Cooper panned that provision, which could give GOP leaders leverage to include unrelated items he may strongly oppose.
The House voted 87-24 in favor of the deal, after little debate and a preliminary vote on Wednesday. Many Democratic members on the floor stood and clapped after it passed, which is usually not permitted under chamber rules. Almost two-thirds of the House Republicans also voted yes. The Senate already approved the legislation last week in near-unanimous votes.
The final agreement also included provisions scaling back or eliminating regulations that require state health officials to sign off before medical providers open certain new beds or use equipment. Senate Republicans demanded the “certificate of need” changes in any deal.
Republicans in charge of the General Assembly for years had been skeptical about expansion, which originated from the federal Affordable Care Act signed into law by President Barack Obama 13 years ago Thursday.
GOP legislators passed a law in 2013 specifically preventing a governor’s administration from seeking expansion without express approval by the General Assembly. But interest in expansion grew over the past year as lawmakers concluded that Congress was neither likely to repeal the law nor raise the low state match that coverage requires.
A financial sweetener contained in a COVID-19 recovery law means North Carolina also would get an estimated extra $1.75 billion in cash over two years if it expands Medicaid. Legislators hope to use much of that money on mental health services.
A turning point came last May when Senate leader Phil Berger, a longtime expansion opponent, publicly explained his reversal, which was based largely on fiscal terms.
In a news conference, Berger also described the situation faced by a single mother who didn’t make enough money to cover insurance for both her and her children, which he said meant that she would either end up in the emergency room or not get care. Expansion covers people who make too much money for conventional Medicaid but not enough to benefit from heavily subsidized private insurance.
“We need coverage in North Carolina for the working poor,” Berger said at the time.
The Senate and House approved competing measures in 2022 but negotiations stalled over certificate of need changes. Berger and House Speaker Tim Moore announced an agreement three weeks ago.
In 2019, Cooper’s insistence on advancing expansion contributed to a state budget impasse with GOP legislators that never got fully resolved.
House Minority Leader Robert Reives of Chatham County wished the budget passage requirement was left out of the expansion measure but remained celebratory.
“I’m just really happy because health care means everything,” Reives said. “Now the onus is on all of us to put together a budgetary document that everybody can live with.”
The state’s 10% share of expenses for Medicaid expansion recipients would be paid through hospital assessments. Hospitals also are expected to receive larger reimbursements for treating Medicaid patients through a federal program that the legislation tells the state to participate in.
The program’s proceeds should help shore up rural hospitals in a state where several have closed.
“This landmark legislation will have lasting benefits for our state by helping hardworking North Carolina families, stabilizing rural health providers and improving the overall health of our communities,” said Steve Lawler with the North Carolina Healthcare Association, which represents hospitals and hospital systems.
In a news release, Moore called Thursday’s passage a “historic step forward to increase access to healthcare for our rural communities” and he said he looked forward to passing “a strong conservative budget” so expansion can begin.
‘We’re Going Away’: A State’s Choice to Forgo Medicaid Funds Is Killing Hospitals
Mississippi is one of 10 states, all with Republican-led legislatures, that continue to reject federal funding to expand health insurance for the poor, intensifying financial pressure on hospitals.
GREENWOOD, Miss. — Since its opening in a converted wood-frame mansion 117 years ago, Greenwood Leflore Hospital had become a medical hub for this part of Mississippi’s fertile but impoverished Delta, with 208 beds, an intensive-care unit, a string of walk-in clinics and a modern brick-and-glass building.
But on a recent weekday, it counted just 13 inpatients clustered in a single ward. The I.C.U. and maternity ward were closed for lack of staffing and the rest of the building was eerily silent, all signs of a hospital savaged by too many poor patients.
Greenwood Leflore lost $17 million last year alone and is down to a few million in cash reserves, said Gary Marchand, the hospital’s interim chief executive. “We’re going away,” he said. “It’s happening.”
Rural hospitals are struggling all over the nation because of population declines, soaring labor costs and a long-term shift toward outpatient care. But those problems have been magnified by a political choice in Mississippi and nine other states, all with Republican-controlled legislatures.
They have spurned the federal government’s offer to shoulder almost all the cost of expanding Medicaid coverage for the poor. And that has heaped added costs on hospitals because they cannot legally turn away patients, insured or not.
States that opted against Medicaid expansion, or had just recently adopted it, accounted for nearly three-fourths of rural hospital closures between 2010 and 2021, according to the American Hospital Association.
Opponents of expansion, who have prevailed in Texas, Florida and much of the Southeast, typically say they want to keep government spending in check. States are required to put up 10 percent of the cost in order for the federal government to release the other 90 percent.
But the number of holdouts is dwindling. On Monday, North Carolina became the 40th state to expand Medicaid since the option to cover all adults with incomes below 138 percent of the poverty line opened up in 2014 under the terms of the 2010 Affordable Care Act. The law, a major victory for President Barack Obama, has continued to defy Republican efforts to kill or limit it.
“This argument about rural hospital closures has been an incredibly compelling argument to voters,” said Kelly Hall, the executive director of the Fairness Project, a national nonprofit that has successfully pushed ballot measures to expand Medicaid in seven states.
In Mississippi, one of the nation’s poorest states, the missing federal health care dollars have helped drive what is now a full-blown hospital crisis. Statewide, experts say that no more than a few of Mississippi’s 100-plus hospitals are operating at a profit. Free care is costing them about $600 million a year, the equivalent of 8 percent to 10 percent of their operating costs — a higher share than almost anywhere else in the nation, according to the state hospital association.
Expanding Medicaid would uncork a spigot of about $1.35 billion a year in federal funds to hospitals and health care providers, according to a 2021 report by the office of the state economist.
And it would guarantee medical coverage to some 100,000 uninsured adults making less than $20,120 a year in a state whose death rates are at or near the nation’s highest for heart disease, stroke, diabetes, cancer, kidney disease and pneumonia. Infant mortality is also sky-high, and the Delta has the nation’s highest rate of foot and leg amputations because of diabetes or hypertension.
Health officials blame those numbers in part on the high rate of uninsured residents who miss out on preventive care.
“I can tell you I have a number of patients who are on dialysis with renal failure for the rest of their life because they couldn’t afford the medication for their blood pressure, and that caused their kidneys to go bad,” said Dr. John Lucas, a Greenwood Leflore surgeon.
Among Mississippi adults, only disabled people and parents with extremely low incomes, along with most pregnant women, are eligible for Medicaid. Many of the ineligible are also too poor to qualify for the tax credits for insurance under the Affordable Care Act, leaving them without affordable options.
The same is true for close to two million other Americans who live in the states that have not expanded Medicaid. Three in five are adults of color, according to a 2021 study by the Center on Budget and Policy Priorities, a nonprofit research group. In Mississippi, more than half are Black.
Gov. Tate Reeves, a Republican, and key G.O.P. state lawmakers argue that a bigger Mississippi program is not in taxpayers’ best interest. The governor says the state’s $3.9 billion surplus would be best used to help eliminate Mississippi’s income tax.
“Don’t simply cave under the pressure of Democrats and their allies in the media who are pushing for the expansion of Obamacare, welfare and socialized medicine,” Mr. Reeves said in his annual State of the State address in January.
Opponents also argue that the newly insured would become dependent on Medicaid and therefore be less likely to work. “I believe we should be working to get people off Medicaid as opposed to adding more people to it,” said Philip Gunn, the powerful Republican House speaker.
Yet in Mississippi’s Delta, a flat swath of fields of corn, soybeans and other crops nearly as big as Delaware, access to any kind of medical care is drying up for lack of money. More than 300,000 people live here, nearly 35 percent of them Black. About the same percentage live in poverty, a rate three times the national average.
Dr. Daniel P. Edney, the state’s top health officer, said he did not set Medicaid policy, and he has been careful not to take sides. But he predicted emerging health care deserts where women would have to travel long distances to deliver babies and more sick people would die because they could not gain access to care.
Of the state’s hospitals, “I have maybe heard of two that are generating any profit,” he said. When he asks hospital executives if Medicaid expansion would help their balance sheets, he said, “they say it’s a game changer.”
He predicted that five hospitals would soon downgrade into mere emergency rooms, where doctors work to stabilize patients, then transfer them to the nearest hospital.
If that happens, some of the sickest will not make it, said Dr. Jeff Moses, an emergency room physician at Greenwood Leflore.
“Where are they going? Davy Jones’s locker,” he said. “It is very dark, and I’m not exaggerating this. I just can’t imagine what will happen to this community if this hospital closes.”
Nine years after states began expanding Medicaid, evidence is growing that broader coverage saves lives. In a 2021 analysis, researchers for the National Bureau of Economic Research estimated that in one four-year period, 19,200 more adults aged 55 to 64 survived because of expanded coverage, and nearly 16,000 more would have lived if that coverage was nationwide.
Other studies suggest why: Making medical care more affordable led to increases in regular checkups, cancer screenings, diagnoses of chronic diseases and prescriptions for needed medicines.
Especially during the first six years of the Medicaid expansion, when the federal government picked up 95 to 100 percent of the cost, many states found that the program was a net fiscal gain. Some states have imposed taxes on hospitals or health care providers to cover their share of the expense, the same strategy used to help fund other Medicaid costs.
Now the federal government is offering a new incentive for the holdouts: As part of a 2021 pandemic relief measure, it agreed to temporarily pay a higher proportion of costs for some existing Medicaid patients if states broadened eligibility.
Mississippi’s office of the state economist has estimated that for at least the first decade, those savings and others would fully cover the roughly $200 million a year that Medicaid expansion would cost the state government.
Tim Moore, the president of the Mississippi Hospital Association, said expansion was “a no-brainer.” The state is so poor, he said, that for every dollar it spends on Medicaid, the federal government pumps four back in.
Polls, including by Mississippi Today and Siena College, appear to show Mississippians support Medicaid expansion, regardless of their political affiliation. Brandon Presley, the Democratic candidate for governor, is highlighting hospital closures as a reason to deny Mr. Reeves a second term in elections this November.
In a possible sign of political nervousness, the governor and the legislature recently agreed to extend Medicaid coverage to pregnant women for 12 months after they give birth, prolonging a federal pandemic-era policy.
The legislators are also trying to prop up the hospitals with a one-time infusion of $83 million or more. But that is a pittance compared with what the state has given up in Medicaid payments.
The state has lost four hospitals since 2008, according to the hospital association, and Dr. Edney, the state health officer, said that it would inevitably lose more. He said he worried most about health care access in the Delta, where he grew up, the child of working-class parents with no health insurance.
On Saturday, Representative Bennie Thompson, Democrat of Mississippi, said victims of a tornado that struck the Delta last week had to be ferried 50 miles away for medical treatment because the local hospital had no power. More Medicaid dollars, he said, would have equipped it with an emergency generator.
An hour due west from Greenwood Leflore, another major hospital, run by Delta Health System, is also in serious trouble. Licensed for more than 300 beds, the hospital one day last month held just 72 inpatients.
Thirty-two of them were kept in the emergency department, partly because of nursing cuts. One upshot is that patients seeking emergency care now wait an average of two hours, four times as long as they should, according to Amy Walker, the chief nursing officer. Some simply walk out.
The neonatal intensive care unit closed last July. Now babies in trouble must be ferried by ambulance or helicopter 125 miles south to Jackson.
Iris Stacker, the chief executive, said the hospital could remain open through the end of the year; after that, she makes no promises. She is hoping federal grants will help keep the doors open, despite the state’s failure to expand Medicaid.
But she said, “It’s very hard to ask the federal government for more money when you have this pot of money sitting here that we won’t touch.”
A top message on Greenwood Leflore’s website is now a request for donations. So far, the hospital has raised less than $12,000.
Mike Hardin, a 70-year-old retiree, was one of a handful of inpatients one recent day. He had come to the emergency room two days before with slurred speech. Doctors quickly diagnosed a stroke and now were sending him home with revised medications.
“They have to do something to keep this hospital open,” he said as he was wheeled out of his room. “The people around this area wouldn’t have any place else to go.”
The hospital’s outpatient clinics are largely still in business, and doctors there say their caseloads are full of impoverished patients who should have been treated earlier.
Dr. Abhash Thakur, a cardiologist, said he routinely saw patients in the late stages of congestive heart failure who had never seen a cardiologist or been prescribed heart medication. Some have as little as 10 percent of their heart function left.
“They are not the exception,” he said, before examining a 52-year-old man who uses a wheelchair because of his heart disease. “Every day, probably, I will see a few of them.”
Dr. Raymond Girnys, a general surgeon, had just treated a man in his late 50s. He said that a week earlier, the man had punctured his foot on a sharp stick while walking in his tennis shoes in a field.
The man did not seek medical attention until the foot became infected because he was poor and uninsured. Dr. Girnys pointed out the irony: If his patient lost his foot, he would become eligible for Medicaid because then he would be disabled.
“If they had insurance, they wouldn’t be afraid to seek care,” he said.
https://www.nytimes.com/2023/03/28/us/politics/mississippi-medicaid-hospitals.html
Analysis: Ten states still spurn Medicaid expansion — and they’re unlikely to budge soon
by The Washington Post - March 28, 2023
North Carolina is poised to become the 40th state to expand Medicaid.
On Monday afternoon, Gov. Roy Cooper (D) signed legislation crafted by the state’s two Republican leaders, an unlikely deal that puts an end to a political battle that has last over a decade.
Writing in The Health 202, The Post’s Rachel Roubein says North Carolina may be the last of the Medicaid expansion holdout states to reverse course for a while. Per our colleague:
Supporters of extending the safety net coverage to hundreds of thousands more low-income adults have repeatedly run into Republican resistance in the 10 states that have long refused the Obamacare program — and another victory isn’t imminent.
“Now we’re down to some of the hardest states to get expansion through,” said Frederick Isasi, the executive director of Families USA, a left-leaning consumer health lobby, though he expressed confidence the remaining states would eventually budge.
Over the years, some steadfast GOP opposition to Medicaid expansion has softened, such as in North Carolina. The 2010 Affordable Care Act required states to extend the safety net program up to 138 percent of the federal poverty level, but the Supreme Court made doing so voluntary.
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