Medicaid, Medicare Policy Changes Could Lead to More Than 25,000 Additional Deaths, Study Says

As essential federal programs in the US, Medicaid and Medicare play crucial roles in offering health care coverage to low-income households and senior patients, respectively. However, researchers say both programs are threatened by either proposed or already implemented rollbacks.

In particular, there are suggested proposals to increase the eligibility age for Medicare from 65 to 67 and introduce work requirements for Medicaid qualification. Meanwhile, the termination of continuous enrollment for Medicaid has recently been implemented. Based on these policy changes, researchers estimated that the adjustment to Medicare policy could result in more than 17,000 additional deaths among individuals aged 65 to 67, while changes to Medicaid policy could contribute to more than 8000 additional deaths among those under 65.

These findings were published in the Proceedings of the National Academy of Sciences of the United States of America.

Since its inception in 1965, Medicare has played a pivotal role in enhancing health care accessibility for seniors and those with disabilities through its affordable coverage options. However, proposals to raise the Medicare eligibility age, such as the recent recommendation from the congressional Republican Study Committee to increase it from 65 to 67 years, are likely to hinder seniors' access to dependable health care nationwide. Raising the Medicare eligibility age to 67 years could leave many individuals uninsured for an extended period, jeopardizing both their physical well-being and financial stability. Estimates from the Congressional Budget Office (CBO) suggest that such a change would lead to a 15% uninsurance rate among Americans aged 65 to 67 years, with uninsured individuals facing a 40% higher risk of death compared with their insured counterparts of the same age.

Medicare and Medicaid stamps | Image credit: Olivier Le Moal – stock.adobe.com

Lacking health insurance poses several challenges. To name a few, uninsured individuals often lack a regular primary care provider, hindering preventive measures even when subsidized, such as with the COVID-19 vaccine. Additionally, these patients tend to delay seeking care until their condition is more advanced and less manageable, increasing the risk of morbidity and mortality, as seen in delayed cancer treatment. Similarly, managing chronic conditions is particularly difficult for uninsured individuals who may forgo necessary treatments and preventive care due to financial constraints, leading to poorly managed diseases and heightened risk of complications.

Based on mortality rates among those aged 65 to 67 who would lose health care access, an estimated additional 9646 lives would be lost annually if the Medicare eligibility age were raised to 67.

“However, the proponents of the policy change focus on the fiscal deficit, but do not consider the mortality repercussions,” the researchers said, point to a CBO analysis of 2 transitional strategies for raising the Medicare eligibility age to 67.

The first proposed strategy would increase the Medicare eligibility age by 2 months per year starting in 2023, taking about 12 years for the new age requirement to take full effect. The other strategy would increase the age by 3 months per year, taking about 8 years. According to the CBO, the first and second proposed methods would lead to fiscal deficit reductions of approximately $15.4 billion and $21.8 billion, respectively, between 2023 and 2028. Money aside, research estimated that these strategies would result in an additional 17,244 (95% uncertainty interval [UI], 3,603-37,230) and 25,847 (95% UI, 5,401-55,804) deaths, respectively, between 2023 and 2028. With the financial lens in mind, federal cost savings would range between about $843,400 and $893,000 per life lost.

“These savings are much lower than the ~12.5 million value of a statistical life previously used for policy decisions by the federal government,” the researchers said.

To maintain health care coverage for low-income families during the COVID-19 pandemic, Congress enacted the Medicaid Continuous Enrollment Provision in 2020, ensuring existing Medicaid enrollees' coverage without additional verifications. However, this provision ceased on March 31, 2023, leading states to initiate disenrollments for individuals no longer eligible or unable to complete the renewal process. The redetermination process—particularly challenging for those in rural areas with lower education levels and limited internet access—poses a risk of coverage loss even for eligible individuals. By November 2023, procedural reasons accounted for 71% of disenrollments nationwide, with some states such as Utah and New Mexico reporting over 90% disenrollments due to procedural issues.

The termination of continuous Medicaid enrollment introduces uncertainties in its full impact due to varying state implementation methods. However, according to CBO estimates, approximately 15.5 million individuals under 65 are expected to lose Medicaid coverage, with 6.2 million becoming uninsured. If the age distribution of those losing coverage mirrors that of the current uninsured population, around 7900 additional deaths are projected, with 40.3% occurring among those aged 55 to 64.

The perennial proposal of work requirements for Medicaid recipients—most recently through the Limit, Save, Grow Act of 2023—introduces further obstacles and bureaucratic complexities for low-income individuals seeking health care access. According to CBO estimates, the implementation of work requirements could result in 600,000 current Medicaid enrollees becoming uninsured, potentially leading to an additional 613 deaths among individuals aged 19 to 54.

To demonstrate the potential impact on morbidity, the researchers also examined a case study focusing on individuals with diabetes who are at risk of losing their health coverage due to these policy modifications. According to them, more than 700,000 Americans with diabetes will lose insurance coverage due to the termination of continuous Medicaid enrollment and the proposed Medicare age increase, including more than 200,000 who rely on insulin. Using the age distribution of diabetes cases in the US, a projected 456,966 individuals (95% UI, 390,417-544,006) under the age of 65 with diabetes could lose access to essential primary care services if Medicaid's continuous enrollment provision is terminated nationwide. Additionally, an estimated 325,613 senior patients aged 65 to 67 with diabetes (95% UI, 296,413-361,216) could lose access to health care services if the eligibility age for Medicare is increased.

“The consequences of this could manifest as untreated diabetes, higher prevalence of diabetic complications, and a reduced quality of life for those affected,” the researchers added. “Furthermore, given the temporal trends of steadily mounting rates of diabetes and prediabetes both overall and at progressively younger ages, the reverberations that we estimate here will likely amplify over time.”

Among patients with diabetes, an estimated 242,600 individuals relying on insulin would lose their health insurance, with over 40% of them being seniors aged 65 to 67. This proposed policy change would further compound the existing health care crisis faced by many seniors patients.

While the researchers said these policy changes are mainly debated in an economic lens, they stressed the public health impact, including the increased mortality and morbidity that could result from proposed changes.

“We find that the health loss greatly outweighs the federal value for a statistical life,” they said. “Our findings underscore the necessity of assessing the health implications of policy changes to guide evidence-based decisions that safeguard the welfare of beneficiaries and the long- term sustainability of these indispensable healthcare initiatives.”

Reference

Pandey A, Fitzpatrick MC, Singer BH, Galvani AP. Mortality and morbidity ramifications of proposed retractions in healthcare coverage for the United States. Proc Natl Acad Sci USA. 2024;121(18):e2321494121. doi:10.1073/pnas.2321494121