Adam Searing: Welcome everybody. We're just gonna wait another a minute or 2 for folks to join. Then we'll get started.
Adam Searing: Just be a minute
Adam Searing: welcome, everyone. We're just waiting a minute or 2 to to get started here. So I think we're gonna
Adam Searing: start very, very shortly. So give it another 30 seconds.
Adam Searing: Alright. So welcome everyone to our latest webinar we're having on for the
Adam Searing: Georgetown University Center for Children and families. Child Medicaid Policy Institute. These webinars are hosted by myself and my colleague, Natalie Lawson. We're here on the faculty at the Center for Children and families in the Mccourt School of public policy here at Georgetown University.
Adam Searing: and if you are in our small group, you have heard much from me and Natalie and others here at Ccf. Before. If you were invited from our larger groups, you are welcome to be here, and we're happy. You're here. So at a time of really great debate about Medicaid, and especially in the current budget debate that's happening in Congress right now. Medicaid is is in the news a lot, and
Adam Searing: both in many in many different ways and regulations and cuts in many ways. And we really see a need for education on what the program is and how it works and what it does. This is. This is what part of our the reason for us doing these these series of webinars?
Adam Searing: And this at this point to this webinar where we were lucky enough to ask, and and she was gracious enough to to agree. Dr. Sarah Miller, from the University of Michigan, Ross school of business.
Adam Searing: was willing to join us today, and she is the associate professor at the Ross School at University of Michigan. She has a Phd. In economics from the University of Illinois at Urbana-champaign.
Adam Searing: and she has very strong research interests in health economics, especially the short term and long term effects of public policies that expand health coverage and in the effects of income on health and well-being. And so I'm a fan of Dr. Miller's work, and I know many others are, too, especially in our smaller groups.
Adam Searing: And so we are just very excited, Dr. Miller, to have you here to talk about how Medicaid affects people's individual health and financial health as well, and without further ado I will turn it over to you. But let me do 3 housekeeping things. So the 1st is, we'll have the Q. And a box, the chats disabled. So please put all your questions in the Q. And A. Box.
Adam Searing: and Natalie is going to be in charge of the questions, and so we will. She will bring those out after Dr. Miller finishes her slides.
Adam Searing: and we are anticipating that we would have. We'll have some significant time for having questions. So don't worry. We're going to get to your questions. And also the final thing is, we are recording this webinar, so that folks who are not able to get here today are able to come. So, Dr. Miller, thank you again for agreeing to speak with us, and take it away.
Sarah Miller: Well, thank you so much for having me and for that extremely generous introduction.
Sarah Miller: Let's see. Now, if I can get my slides up here.
Sarah Miller: Alrighty, do.
Sarah Miller: Okay. Great. Well, hopefully, you guys can see that all right, you know, as was just discussed, this is a really timely moment to be having these discussions, although I feel like it, sort of is always timely. There's always different policy debates and controversies and discussions going on around the Medicaid program, and part of the reason for that is that Medicaid
Sarah Miller: is a big program, and it covers a lot of people. It's the largest insurer in the United States, and it covers low income individuals and some of our most disadvantaged and vulnerable citizens and residents. If you enroll in the Medicaid program, you're able to get health care that is free or low cost at the point of care, and as of the sort of latest statistic that I pulled, which is from the 2024 report, you know, over 98 million
Sarah Miller: full time. Equivalent enrollees were enrolled in the program in 2023, and it cost, you know, over 890 billion dollars in that fiscal year. So I think it's quite fair to ask a question that's been asked
Sarah Miller: a lot by policymakers. Which is, what are we getting for our money here is this program really generating the sort of benefits to enrollees in terms of their health, their well-being, their financial status that we might expect for such a big and such an important program. And this is a huge question. This is a topic that there have been hundreds and hundreds of
Sarah Miller: journal articles written about as certainly far more has been written than what I can talk about just in this short webinar. So I'm going to use the presenter's prerogative and talk mostly about the papers that I've written myself, or those that have been written by co-authors. But of course this is not comprehensive, so I'm happy during the Q. And a. To talk about other papers or other research findings that I am not able to talk about just during these slides.
Sarah Miller: So before we jump into the data, and you know, what does the research say and the analysis? I think it's good to take a step back and say.
Sarah Miller: Okay, what might we expect Medicaid to do? What would be some of the outcomes? We might think to look to be changed by changes in Medicaid eligibility. I think one that was just mentioned, which I think is very top of mind, is given. How expensive medical care is in the United States, and how disruptive financially an unexpected illness or injury can be.
Sarah Miller: We might expect, if you'd otherwise be uninsured, that Medicaid could reduce financial hardship and improve households financial situation, either because they're no longer struggling to pay medical bills or because they don't have. You know, medical bills or other bills, going into collections and ruining their credit score and making it harder for them to make investments.
Sarah Miller: so we might expect some improvements in financial outcomes. And there's a lot of papers that that look at this, and do indeed find that policies that expand Medicaid eligibility or induce people to enroll into Medicaid do lead to better financial outcomes.
Sarah Miller: Secondly, we, you know, kind of one of the direct effects we might expect is increasing access to health care, and in turn, causing people to use more medical care. I think it's quite plausible that this would happen. Their out-of-pocket costs are decreasing, and people can use more care.
Sarah Miller: On the other hand, some some States pay providers very little when it comes to seeing Medicaid patients, and so there could be barriers to access. If many providers don't accept Medicaid as insurance.
Sarah Miller: I think, however, both of these 2 kind of pathways have been pretty well established in the literature. I'll show a little bit of results from these kind of topics. I think the question that's a little bit harder or trickier as a researcher to really nail down is.
Sarah Miller: if a Medicaid induces people to use more medical care, which it seems like it does. Do we get health outcomes to improve as a result? And I think this is a really important question, both
Sarah Miller: because of it's just an important outcome for beneficiaries. But it's also an important program goal. And it's something that policymakers and public health officials want to see the program do.
Sarah Miller: And it's especially important in the context of the United States, where in the Us. Low income, people have much, much worse health outcomes in terms of longevity or chronic disease burden than higher income, people who are otherwise similar, besides income. Now that kind of relationship between income and health is not particular to the Us. We see that relationship in every country in the world, but it is a bit of a stronger relationship in the Us. Than other countries. So I think it's a natural question to ask.
Sarah Miller: since Medicaid is a program that is targeted to lower income or vulnerable or disadvantaged groups. Can it help reduce some of this health inequality that we see, and that we might be concerned about?
Sarah Miller: However, although this is a really important question. The role of Medicaid in generating improved health outcomes.
Sarah Miller: It has a lot of challenges for people like me who do research on this topic. It's not very straightforward to measure the impact of Medicaid on health for a few reasons. First, st you can't just compare people who enroll in Medicaid to people who don't enroll in Medicaid and look at the difference in their health outcomes. You might be enrolling in Medicaid, because you know that you're sick, and you're going to need medical care, or you might be medically. You might be eligible for Medicaid, because your illness has made it harder for you to earn more money in the labor market and have a higher income.
Sarah Miller: So you need to have some sort of variation in Medicaid eligibility that's unrelated to the characteristics of the people signing up.
Sarah Miller: Now there's been a couple opportunities to look at random. Assignment of Medicaid eligibility. The Oregon Health Insurance Experiment is a really famous example of a situation where there was randomly assigned Medicaid eligibility. The Irs also did a really interesting experiment, nudging people to sign up for Medicaid, but for the most part it's hard to find random assignment. We don't usually randomly give people insurance or not give people insurance.
Sarah Miller: A second challenge is that it can be hard to actually measure health. How should we measure health? People's subjective feelings of how healthy they are might not reflect their actual underlying health and some things that we can kind of all agree are indicators of poor health, like early mortality don't happen very frequently, and so there can be kind of statistical issues with having enough power to detect these effects.
Sarah Miller: And then, 3, rd which I think is potentially the biggest challenge on this topic is, you might be able to enroll in Medicaid, but it might take a long time for the health benefits to actually materialize. It's not obvious that if you enroll in Medicaid you're going to start seeing better health in a couple months, or 6 months, or even in the 1st year or 2, you need to be able to get your conditions diagnosed and manage and use medical care, and eventually health should be improving down the line. But we might not expect it to materialize immediately.
Sarah Miller: So I'm going to try to talk about some papers that try to get around these challenges 1st by using with, if if not random assignment, using sort of changes in eligibility for Medicaid that are unrelated to people's individual choices, to sign up
Sarah Miller: trying to use administrative records on health or financial outcomes, to get at these objective measures of health.
Sarah Miller: and then, when possible, and of course it's not always possible, seeing if we can take a longer time, horizon and look at long-term benefits or long term effects that might materialize, not immediately, but maybe down the road.
Sarah Miller: So that's the plan.
Sarah Miller: all right. So I'm going to talk briefly about sort of 3 different kind of important groups in the Medicaid program. So this is a plot of the person years enrolled in Medicaid in millions on the Y-axis with year on the X-axis, and it starts in 1960, and it goes through the early 2,020 s.
Sarah Miller: And there's sort of 3 really big points of expansion in this program. And I'm going to talk about these 3 populations that it was expanded to so 1st expansions to pregnant women and children starting in the eighties and in the early nineties. Then there were further expansions to children. Later in the nineties, and then in 2014, there were expansions to low income adults under the Affordable Care Act.
Sarah Miller: So these are kind of the 3 3 little snapshots I'm going to try to give in this talk.
Sarah Miller: So first, st Medicaid expansions for pregnant women.
Sarah Miller: Over the course of the 1980 s. Through the very early 90 s. We saw a really rapid expansion in eligibility for prenatal medicaid to low income women.
Sarah Miller: So this graph that I have on the left plots the fraction of women of childbearing age that would be eligible for Medicaid in the event of a pregnancy on average in the United States, and, as you can see, it starts in the early eighties at under 15% or under 0 point 1 5 fraction eligible. By the time it gets to the early nineties it's almost up to 50%. So this is a really rapid and dramatic expansion of Medicaid eligibility that occurred to pregnant women.
Sarah Miller: So it's a very famous study that was done by Janet Curry and John Gruber in the 19 nineties called Saving Babies, that used this expansion of Medicaid, and the fact that expanded differently across different States to look at how that affected infant health, and they find large decreases in infant mortality, as well as decreases in the rates of having low birth, weight, infants for the most disadvantaged families.
Sarah Miller: So this indicated, there were these kind of early life health benefits.
Sarah Miller: other research in economics and epidemiology and health services. Research has shown that early life health is a really important predictor of later life, health and outcomes. So people who are born with better health tend to do better later in life.
Sarah Miller: So one natural question here is, do these early life health benefits that happened because of these prenatal expansions translate into longer term benefits.
Sarah Miller: So there's I'm going to talk about a couple of papers on this that suggest that the answer is yes.
Sarah Miller: So 1st in a paper I wrote with Laura Weary, who's at Nyu
Sarah Miller: that was published in 2019. We look at the same sort of variation that Curry and Gruber look at and take advantage of the fact that some States expanded more and some States expanded less in terms of their eligibility over time. So we link information on Medicaid exposure of adults to their state and year of birth. And then we look at their adult health and human capital, based on whether their mothers would have been eligible for Medicaid at the time of the prenatal care expansions.
Sarah Miller: and what we find is that those whose mothers benefited, who were in low income households and their mothers benefited from having additional prenatal medicaid eligibility, had fewer chronic illnesses and fewer hospitalizations later than life, and also had some better economic outcomes
Sarah Miller: and the reductions in the hospitalizations that we see offset over a quarter of the original cost of the expansions of medicaid eligibility to low income pregnant women.
Sarah Miller: A second set of authors at Harvard did a reanalysis of this data to calculate the total benefits, not just the medical care benefits, but also the economic benefits of having better economic and educational outcomes. And actually, their analysis concluded, based on the work in the Miller and Weary paper, that if you added up the public and the individual benefits. It was 14 times higher than the original cost of expanding prenatal medicaid eligibility.
Sarah Miller: So this is looking at again. Still relatively young cohorts. I think it's possible that these, you know benefits could continue to grow, and I'll say the Hendren and Sprunkheiser paper does project project out what the benefits will be. That's 1 reason they arrive at very large total benefits.
Sarah Miller: So I think a second question that my co-author and I had along with some other economists that we were working with is
Sarah Miller: If
Sarah Miller: people who benefited in infancy are now healthier as adults, now they're at the age where they're having their own children. Remember, these expansions happened, you know, in the very end of the seventies, early eighties. Many of them have had their own children
Sarah Miller: are their own children healthy? Are there any intergenerational or multigenerational benefits?
Sarah Miller: So that's what we look at in this next paper by East Miller, page and weary, which was published in 2023.
Sarah Miller: You can think about the 1st generation here on this figure of looking at
Sarah Miller: children who benefited when they were in utero or in the 1st year of infancy.
Sarah Miller: they grew up to have healthier, healthier experiences in adulthood as well as higher economic outcomes. In adulthood. Now they had their own children, and our question in this paper is again using these linked administrative records is the second generation healthier as a result
Sarah Miller: of of these Medicaid eligibility changes.
Sarah Miller: So what we do to look at this is, we look at States who had very sharp increases in medicaid eligibility, and we compare them. We look at parents were born in those States relative to States where Medicaid eligibility was relatively flat.
Sarah Miller: So you can see on the left hand side. Here the states that we consider the treated group are in blue, and it's sort of flat before the eighties, and then it's they kind of take off, whereas the control states are in red. And then it's again, it's kind of flat before about 1980, and it remains flat afterwards.
Sarah Miller: So we operationalize this analysis, using what's called a difference in differences design, where we look at kind of changes in the control state outcomes and changes in the Treated state outcomes. So here, on the right hand side, I'm just going to take an extra moment to explain this, because there's kind of a lot of graphs that look like this.
Sarah Miller: Here we have the years before the expansion occurred, before they increased eligibility to low income, pregnant women.
Sarah Miller: and the fact and these dots are telling the change in the and the outcome variable in the treated versus the controlled States. So the fact that these dots are all close to 0 and small indicate that before the policy change happened these states were very similar. And then, after the policy change happened, you can see that there's a significant increase in the fraction of women who would be eligible for Medicaid in the event of a pregnancy.
Sarah Miller: The drawings are so. This is kind of the approach that we take here.
Sarah Miller: So what we find is that, yes, not only was the 1st generation benefiting from these expansions later in life, but their children also ended up being healthier too. So this figure is showing that same sort of design where we look at changes across the 2 groups of States before the expansion, and then changes after. And what you can see is before the expansion. They had very similar birth weights. This is the second generation's birth weight. After the expansion, birth weights start to increase in states that
Sarah Miller: of parents who were exposed to the 1st generation. Medicaid expansions. We also find improvements in other measures of infant health, like the probability of being very low birth, weight, or very preterm or small, for gestational age.
Sarah Miller: So that suggests that these prenatal expansions had actually really big benefits that extended beyond just that initial period of pregnancy and prenatal care that was received by the Enrollees. The original curry and Gruber study was really groundbreaking study, and showed all these health benefits. But even though they found big health benefits that was still sort of too small in a sense, to capture the overall lifetime and multigenerational benefits of the program.
Sarah Miller: So the fact that we're seeing kind of these long term benefits suggests, you know, as we go into the future, they might be even bigger.
Sarah Miller: This was surprising to us. But again, it made sense in the context of other research that showed that really that early life environment is really, really important. And if you can get that right a lot of times, you can have really big improvements along a lot of dimensions throughout your entire life, and that has not just been a finding in Medicaid. That's been a finding across many, many contexts, and many different positive and negative things that have happened.
Sarah Miller: So I think a natural question, then, is, okay. This very early life intervention seem to generate some improvements. But what about when kids are a little bit older? Remember, that was sort of the second big expansion on the graph was expansion to children in poor households.
Sarah Miller: So I'm going to talk about next. Some analysis that we did, examining expansions for Medicaid to children in low income households.
Sarah Miller: So to look at this.
Sarah Miller: we take advantage of a kind of cutoff that happened as a result of a policy. So in the 19 eighties, if you remember that graph Congress started expanding Medicaid eligibility to low income children, and many of the expansions applied specifically to children born after September 30, th 1983.
Sarah Miller: So if you were born September 28, th 1983, which happens to be my birthday. Actually, you would not benefit from a lot of these expansions. So you might be very similar to someone born a couple days later. But you would not be able to enroll in Medicaid because it was based on a birthday cutoff.
Sarah Miller: So what we do in this is, we look at kids who are born right before and right after the cutoff, and then we follow them throughout their adulthood, and we look at their adult health outcomes.
Sarah Miller: They'll talk about the effects on mortality hospitalizations and emergency department visits.
Sarah Miller: So 1st of all, you know, the effect of this cutoff on Medicaid actual enrollment is from the National Health Interview Survey. One thing we noted was that black children were more likely to be in income, eligible households. And so it had a much bigger impact on enrollment for black children who experienced a 5 to 8 percentage point enrollment, which is, you know, up to a 25% enrollment in Medicaid. If you were born right after the cutoff versus right before. So this figure shows your birth month.
Sarah Miller: So both of these figures show how close to this cutoff you were born, and you can see that those who were born kind of right before the cutoff have lower medicaid coverage
Sarah Miller: and those who were born right after the cutoff. So if you were born right after, you might be similar on other dimensions. But you're more likely to sign up for this.
Sarah Miller: all right. So going off of that that kind of setup
Sarah Miller: Meyer, and wary. So I'm not an author on this paper, but my co-author, Laura Wary, wrote this paper with Bruce Meyer, University of Chicago. What they find is that
Sarah Miller: when examining mortality rates, so the probability of death as teenagers, and at the time this was the oldest, they could examine these cohorts because this is conducted a little bit earlier. They found that if you were born right after the cutoff and you were able to sign up for Medicaid, you actually had lower rates of mortality in between the ages of 15 and 18.
Sarah Miller: So then, in some follow up work, we look with coauthors at not just mortality, but also hospitalizations, especially for chronic conditions that we might think would be affected by Medicaid. And we see that by age 25, just like we're seeing for older ages in terms of mortality. We're seeing some opening up of hospitalizations where those who were able to enroll in Medicaid in childhood have lower hospitalizations in it.
Sarah Miller: So what have we learned from this in terms of childhood medicaid expansions? It's not just the very early life prenatal medicaid expansions that are generating these long term improvements, but also expansions that occurred during childhood. So most of these expansions that were driven that were related to this cutoff happened between the ages of 8 and 14. So later in childhood, those who
Sarah Miller: were able to gain Medicaid eligibility and enroll in Medicaid had more access to care in childhood, and as they grew up that was reflected in better health outcomes. If we look at cost savings, we put the cost per life saved at about 1.7 7 million per life
Sarah Miller: additional, their savings from hospitalizations. So this is once we take into account discounting and everything. This is defraying 2 to 4% of the cost of the original childhood coverage. This is not including other potential benefits that could be happening over the long term, such as like improved wages, and things like that. In fact, there's, you know.
Sarah Miller: again using the prerogative to talk mostly about my own work. But there's really a large and growing body of work that has traced out the impact of this childhood Medicaid coverage on improved outcomes later in life. So there's a number of papers there. If you're interested, I'd encourage you to look them up. If you look in the light gray, those are the citations.
Sarah Miller: A similar study that uses the same kind of variation and uses Irs data find found that the government is recouping 58 cents per dollar that they spent on childhood medicaid eligibility expansions by age 28. So there's kind of a wide variety of cost savings measures, but it does look like having better access to medical care when you're younger is generating adult benefits for you in terms of your health and your economic outcomes.
Sarah Miller: Okay? So we talked about very early life, prenatal care and infant care that seem to generate long-term outcomes. We talked about childhood Medicaid being able to access medical care as a child that seemed to generate like long term health and economic outcomes. But what about for adults? Are there any? Is there anything that we can say about the effect of Medicaid eligibility and medicaid expansions in an adult population?
Sarah Miller: So there's again a lot of great papers written on Medicaid expansions for adults, and many of them use the expansions of Medicaid eligibility that occurred as a result of the affordable Care act
Sarah Miller: so the Affordable Care Act, originally as written, intended for the law to make Medicaid eligibility available for all adults who are in households up to 138% of the Federal poverty level in all States. But, as we know, there was a Supreme Court decision in 2012 that made these expansions optional. And so not all States decided to take up the Medicaid expansion.
Sarah Miller: But starting in 2014, many States did, and currently 40 States and DC,
Sarah Miller: you know, over time, have adopted these aca medicaid expansions with 10 States still remaining, not adopting.
Sarah Miller: So this this situation is you know, unfortunate if you're low income and you live in a non adopting state. But it's very fortunate if you're a researcher who's trying to understand the impact of these expansions.
Sarah Miller: So we are able to.
Sarah Miller: sorry we're able to take advantage of the fact that it is a very different expansion experience in different states to look at what was the impact of the expansions?
Sarah Miller: See? Okay? So first, st we look at the impacts of the adult Medicaid expansions on survey responses. And this is a paper also written with Laura. Wary, we look at low income survey responses to the National Health Interview Survey, and we examine changes in coverage access to care and financial outcomes in states that expanded versus states that did not expand.
Sarah Miller: So we're using the same sort of difference in differences, style, technique, where we look at changes before and after among states that didn't expand versus states that did expand.
Sarah Miller: This graph here is showing the effect on Medicaid enrollment. So, as you can see, Medicaid trended very similarly prior to the expansions in non-expansion and expansion states. So that's this is the pre period. And you see, these coefficients are all very close to 0. And then, after we see that there was a big increase in this population among states that that opted to expand as we might expect.
Sarah Miller: So we find that there was about a 16.4 percentage point increase in Medicaid enrollment at the time of the survey for this low income sample in states that opted to expand as a result of the expansions, there's also a corresponding decrease in the probability of being uninsured of a little bit more than 10 percentage points.
Sarah Miller: So next we look at different measures of changes in access to medical care. So it's kind of that second hypothesized outcome. And so we look at the probability. A respondent reported that he or she needed medical care, but could not afford it in the last 12 months, and we see about a 5 percentage point decrease in this report of needing medical care and not being able to afford it
Sarah Miller: now. I don't want to go over every single outcome, but I would encourage you to check out the paper, but we look at lots of different measures of being able to access care and financial stress and financial burden, and they all improve really significantly.
Sarah Miller: So we see improvements in saying I couldn't get follow-up care after an initial appointment that people are much less likely to say they couldn't get that type of care that we see improvements in their ability to access specialist care. We see improvements in people saying, Oh, I'm delaying care that I need because I'm worried about medical bills, or I'm just worried about medical bills. I'm worried what will happen if I need medical.
Sarah Miller: So we see kind of improvements in a lot of dimensions of financial well-being as well as medical care.
Sarah Miller: So I, again, not wanting to, you know.
Sarah Miller: try to put too much content in into this presentation. But there have also been many other studies that look at this financial and access dimension. I have some work that uses actual people's actual credit report data and sees what happens when people are able to enroll in Medicaid because of the affordable Care Act expansions. So you can look on credit reports and see things like medical bills sent to debt collectors, credit scores, other unpaid bills.
Sarah Miller: bankruptcies and evictions, and other markers of financial well-being, and all of these I shouldn't say all of these, but the ones that I just mentioned. There are some that don't change, the ones that I just mentioned improve when States expand medicaid eligibility. So I think this is some good evidence that there's not just these health benefits, but also these financial benefits.
Sarah Miller: So there's some. So looking at adults, there's some access benefits. There's some financial benefits that can be measured on credit reports. I think you know, the question is, are these translating into better health? We don't have the benefit of having very, very long term ability to look back very, very long term, because these expansions were relatively recent. So we don't know 30 years in the future what it will be.
Sarah Miller: But we're going to try to look at potential short term benefits and see if they're growing or changing over time.
Sarah Miller: So in a paper with Laura Wary and Norm Johnson, we try to match these
Sarah Miller: these benefits, these improvements in access and financial outcomes, to improvements in health.
Sarah Miller: To do this, we have some new linkages that we conduct between survey data and administrative records of mortality. So in the Survey data the American Community Survey, we're able to see characteristics that determine medicaid eligibility like, what was your income before the expansion occurred? So we know that only low income people benefited from this expansion. So we're able to really focus on a group where we really think the benefit of the Medicaid eligibility expansions is going to be high
Sarah Miller: in our paper, we focus on adults who are age 55 to 64, because mortality risk is higher than among younger age people. But recently an independent team replicated this work using a bigger data set. And they found that the same effects that we see in the older group
Sarah Miller: are also present in the younger group. They're just proportional to baseline mortality risk. So Weiss and Meyer have a paper basically replicating this analysis and finding kind of big effects that also exist in the younger group.
Sarah Miller: So I'll talk to you about these effects. We're seeing in the older group. But bear in mind that they probably are also present in the younger group.
Sarah Miller: So, and the approach that we take is the same as with the other analysis. Where we look at the changes in this high impact population in the expansion states before and after the Reform versus the same change in the non expansion states.
Sarah Miller: So here's the figure for mortality, and what you can see again, what we kind of like to see, and what we tend to see is that before the Aca expansions are adopted, mortality rates are trending very similarly across expansion and non-expansion states. In this very low income group.
Sarah Miller: Then we start seeing significant reductions in mortality that occur after the expansions take place, and these effects seem to be growing over time. So we see a reduction in mortality rates. Mortality is on the X-axis here of about 0 point 1 3 2 percentage points, which is about a 9.4 decline in mortality relative to the average mortality rate in the control states.
Sarah Miller: And when we dig in and look at what are the causes of mortality that are being the most affected they seem to be. It seems to mostly be driven by disease, related causes so internal causes of death rather than things like car accidents or or drug overdoses, or that
Sarah Miller: so what does that mean in terms of excess debts. Well, I guess you could. You could. You could
Sarah Miller: frame it both ways. You could say. On one hand, the expansions reduced mortality by about 19,200 fewer deaths over this 4 year period that we look at
Sarah Miller: Or the Flip side is that there were about 15,600 excessive deaths in the non-expansion States. That wouldn't have occurred if they had instead decided to expand Medicaid under the Affordable Care Act.
Sarah Miller: So this is consistent with prior work that, looked at similar population level changes in mortality both from the Medicaid expansions and from earlier sorry. The Aca expansions and from earlier Medicaid expansions.
Sarah Miller: And it's also consistent with experimental evidence that has found mortality effects associated with insurance coverage. So this golden Larry and Mccubbin paper that I'm citing was a huge experiment they did in the Irs, where they mailed, randomly selected people who didn't have insurance a letter and said, You can sign up for insurance. You're going to pay a penalty if you don't have insurance, and tried to induce them to sign up, and they found that those who received the letter
Sarah Miller: were more likely to sign up, and also had lower mortality over the next few years as a result.
Sarah Miller: Okay, so I know that I tried to put kind of a lot of content into a relatively short webinar, but I want to wrap up so that we have plenty of time for Q, and a. And additional discussion. So the conclusion of this these analyses is that Medicaid generates, I think, pretty meaningful health and well-being improvements
Sarah Miller: for expanding medicaid coverage and eligibility for pregnant women kids and for low income adults.
Sarah Miller: I've only talked about a small collection of studies. Of course there are many other studies that have been done. There's also many, many measures of health and well-being. So I've talked about mortality, and I've talked about access to care and things you can see on credit reports. But of course that is only a small piece of the pie in terms of all the things that can change. If you go from having no insurance and not being able to access, care to having Medicaid eligibility and medicaid in bulk.
Sarah Miller: So I think there's still a lot of work to do. But this is kind of my impression of the state of the literature. I think there's certain populations that haven't been studied as much, for example, undocumented immigrants who in some States are able to enroll in certain types of programs as well as spillovers onto.
Sarah Miller: you know, other family members, or what is Medicaid doing at a community level? So I'm hoping, and I'm optimistic that researchers can kind of continue to dig into these these questions. Since this is going to be a
Sarah Miller: a program that
Sarah Miller: it inspires a lot of debate and a lot of controversy, I think, for many years to come.
Sarah Miller: Thank you.
Natalie Lawson: Thank you so much, Dr. Miller. We really appreciate it. That was a really great
Natalie Lawson: you know. Review of the literature, and a great reminder of how important Medicaid is to people in their health, especially in recent months, we've been really getting caught up in the program's financing and the programs rules. So I think it's really great to have just a nice review of how important it really is to individuals.
Natalie Lawson: so we'll go ahead and get started with our little Q&A portion. So for everyone who's in the audience, please remember that you can submit via the Q&A function. The chat is disabled. So the Q. And a function is how you can do that. And I'll start off with our 1st question.
Natalie Lawson: which is, how did continuous coverage in Medicaid during the public health emergency of the pandemic. How did that impact your analyses that you have done recently.
Sarah Miller: Yeah, that's a really great question. So all of the papers that I just talked about were done using pre pandemic data. And I think researchers are still really working on disentangling the impact of the continuous coverage provisions. It's a really important
Sarah Miller: policy to understand, because there's a lot of churn in the Medicaid program. And so there's, you know, there's a lot of interest in finding ways to have better continuity and better. You know continuity in your provider relationships, etc.
Sarah Miller: The thing that's very challenging from a researcher perspective is, there's a lot of things going on with health during the pandemic right? So the challenge to researchers is disentangling what health or wellbeing effects we might observe that are due to the continuous coverage provision, and what might be due to things like.
Sarah Miller: you know, the recession that happened at the beginning of Covid. Uncertainty about you know what Covid is going to do, or fear of getting the disease, and that has proven to be a really challenging but important question. So I would say that that's still in progress trying to tease that apart.
Natalie Lawson: Great. Thank you.
Natalie Lawson: Another question we have is kind of touching. You touched a little bit on
Natalie Lawson: You think you mentioned some medical debt, but I wanted to kind of dig into that a little bit more. So, you know, medical debt in the Us. Is a pretty big deal, especially there's a fair number of folks with very high amounts of medical debt. Can you talk about the impact that Medicaid has on medical debt, or what having Medicaid
Natalie Lawson: could or would do for someone's debt, load versus someone with a different type of health coverage.
Sarah Miller: Yeah, so that's a great question. So there have been a lot of studies finding really big impacts of medicaid enrollment and eligibility on medical debt, reducing medical debt. I think one thing to keep in mind just as we talk about this is, there is kind of 2 sides of a coin. Someone's medical debt is another provider's unpaid bill. So being able to reduce medical debt is not only good for
Sarah Miller: the beneficiaries and the patients, it's also good for the provider. So I think kind of a flip side is. There has been some research suggesting that the Medicaid expansions through the Aca were also good for hospital revenue and hospital finances. But yeah, looking at the consumer side, we definitely see a reduction in medical debt. A lot of medical debt doesn't
Sarah Miller: get collected on by the hospital, it gets sold to a 3rd party, so the hospital doesn't necessarily put a lot of resources into collecting, but it'll sell it to a 3rd party. And so that's usually how it's reported on. The on. The credit report is like a reduction in 3rd party collections, and I'd say, there have been actually many studies that find pretty substantial reductions in 3rd party collections of, you know, somewhere between $401,500 on
Sarah Miller: average, for people who are, you know, gain Medicaid enrollment through a policy change?
Sarah Miller: So I think that can be really important. There have. I want to also highlight.
Sarah Miller: This is also something that's kind of more recent than this literature is that the Cfpb actually did a lot of work to get the credit. 3 big credit reporting agencies to reduce the importance of medical debt in terms of credit scores. Medical debt is actually not very predictive of default risk. So you know, the goal of a credit score or the goal of a credit report is to try to tell a lender, hey? If I make a loan to this person. Are they going to actually pay me back?
Sarah Miller: But the analysis shows that medical debt just is. It's not the same as not paying your credit card bill right? A lot of people get medical debt because of something completely out of their control that they don't have a lot of control over. So it's actually not very predictive of default. Right? And so it's been kind of removed. A lot of older medical debt has been removed from credit reports, and it's also been kind of played down in determining credit score, which I think is
Sarah Miller: you know. Another another good move. So I think earlier, especially earlier on insurance status, played a really really big impact. But fortunately there's been under the Biden Administration. There were these changes that I think is also going to benefit people on Medicaid, and also people with private insurance or Medicare.
Natalie Lawson: Great
Natalie Lawson: thanks. We got another question. Are you aware of any studies that look at the effect of risk-based Medicaid managed care on access to care or health outcomes for children, and then follow up for parents or other adults as well.
Sarah Miller: Yeah, that's a great question. So I've been sort of talking about Medicaid, right? But there's actually lots of different types of Medicaid. There is sort of traditional Medicaid. There's most most medicaid beneficiaries are on Medicaid managed care plans, and even within Medicaid managed care. Different plans are different, and there's been some really interesting work.
Sarah Miller: Looking at, you know, how do plans differ within the Medicaid Provider space? You know. And what people have found is that some plans just function a lot better than other other managed care plans. Right? So
Sarah Miller: I'm thinking of, like there was a study where patients were randomly assigned. If they didn't pick the plan they were randomly assigned a plan to be on, and some of those plans generated. A lot of health benefits, and other ones
Sarah Miller: were less successful. So I think the question of like, what's the impact of being assigned to a Medicaid managed care plan that has risk adjustment or different ways of dealing with the risk of the population. It kind of is very context specific. I will say there has been some work saying that some of the really
Sarah Miller: difficult high cost cases don't do as well on managed care plans. So
Sarah Miller: technology, dependent medical needs for kids, for example, as it's been a group. A highly disabled kids have often been carved out of managed care, and increasingly, they're being moved on to managed care. And there's some evidence that there can be some disruption there. If you know, for very, very high need group. But yeah, I think there's a lot of heterogeneity, and I think it's a great, a great question.
Natalie Lawson: Thanks. Another complicated one. So
Natalie Lawson: I know a lot of the groups that we work with at Ccf. And therefore possibly a lot of folks listening in today might be kind of more on the, you know, advocacy side of things, especially right now. There's a lot going on potentially with Medicaid very soon. So I guess the question would be, you know, how can we use this information, this research that you've, you know, gathered and cultivated and done. And how can we use that information to inform the current debates going on about cutting
Natalie Lawson: potentially a lot of money out of Medicaid funding.
Sarah Miller: Yeah, I think you know I'm I'm not an advocate. So the advocates actually probably have better ideas than I do on this. But I will say that I, you know, at the University of Michigan I lived in Michigan when we, the State, decided to expand Medicaid a bit later in 2014, and we had a Republican Governor, Governor Snyder. We had a Republican controlled State House, so not a State that is naturally
Sarah Miller: super open to expansions in, you know, government spending in general right? Like, I mean, that's kind of. And yet the State still decided to do this expansion, and I think it was very successful. Many, many, I mean. It was one of the largest expansions. We had tons of Medicaid, eligible people, and I think the residents of the State of Michigan are pretty happy with what what happened. And so, you know, I remember those debates and discussions.
Sarah Miller: and I think a lot of the things that I'm interested in in terms of research, like.
Sarah Miller: you know, financial burden of low income households and health of kids and things like that. I don't want to say that those weren't important. Of course those were really important, but there were also economic arguments that people made that, I think, were very persuasive to the State leadership. At the time a lot of hospitals were closing. There was a lot of concern about hospitals being financially stable, being able to support healthcare in rural communities
Sarah Miller: in the Detroit area. You know, we had a lot of you know the market. There was a lot of turbulence in the hospital markets. And so I think the argument that it's not just like I said. One person's medical debt is another provider's revenue. There's also an argument to be made about
Sarah Miller: hospitals being big employers, and the revenue that they're getting, and them actually being able to like recoup, you know, be paid for the services that they provide that Medicaid provides a benefit, for there were also a lot of arguments about the workforce and trying to get the workforce to be more productive and part of that, being making sure that they were healthy. So
Sarah Miller: again, I'm not an advocate, but just like watching what was persuasive in my home state, was very informative for me.
Natalie Lawson: Right that a lot of the economic arguments can be often what what can help persuade people? And I think I'm actually gonna kick it over to Adam, who, I think, has a few questions as well.
Adam Searing: I have some burning questions for you. So
Adam Searing: Dr. Miller, so I just want to follow up a little bit on what you were just talking about about the you know, we have this current debate that's going on about how much to fund Medicaid, and I think a lot of the the folks that are on this call, and you know we have a lot of
Adam Searing: children's groups and other and other folks who deal with the Medicaid program all the time in a lot of different different areas. And they do use like your research, other folks research. They, you know, I always think that Medicaid and Medicaid expansion especially has to be one of the most studied health policy changes in history, because it became this natural experiment. Right? Like you were alluding to that there were these States that done it, and states that hadn't. And you know, what more could a
Adam Searing: researcher want than 2 groups of similarly situated people who are affected differently by the same policy. And so I just, you know, as somebody who's published in this in this area and who's respected in this area.
Adam Searing: You know, I think our the a lot of these groups want to use the very best research out there. And you know this is science. And you know it's there's not going to be a
Adam Searing: a definitive answer. You know, we're always going to be looking for for further, you know, information and acknowledging that that you know not everything, you know, turns out exactly how you want. You're trying to figure out what are the actual effects as close as you can and acknowledge, be humble, and say, Well, you know it might change. But what if, with all that in mind, what are some of the strongest findings. And you know, in studies that you've
Adam Searing: either
Adam Searing: done yourself or or seen work with other people on, or seen or seen around these issues in the last few years. Like, if you were.
Adam Searing: you know, a group wanted to talking to somebody, saying, Here's really some of the best research out there. What, what are, what would be? You know your your top few.
Sarah Miller: That's a great question. There's a lot of really great papers out there.
Sarah Miller: Obviously, the experiments are really compelling because you have an actual experiment, right? So I mean the Oregon Health Insurance experiment, I think, was incredibly influential. So if any people are not familiar with it, the State of Oregon only had, you know, it had a Medicaid program. Enrollment had been capped. They were not allowing new enrollees, and over time people attrited from the program naturally, and they got to the point where they had the budget to enroll about 10,000 additional low
Sarah Miller: adults into their into their program called Ohp Standard.
Sarah Miller: And what happened was, they knew way. More than 10,000 people would be interested in signing up for this program right? And so, to make it fair, they made it random, you were able to apply, and then it was random whether you were picked
Sarah Miller: to be allowed to enroll in the program or not, and a lot of they were totally correct that many more than 10,000 people really wanted to sign up for Medicaid. And so you had a nice situation where we had an actual, randomized, controlled trial. And I think a lot of the things we've learned about Medicaid from the Aca. We've also seen in this experiment, which is, of course, very reassuring that you're not finding totally different results. So they found really big improvements in financial
Sarah Miller: outcomes. They found big improvements in like the probability of having catastrophic what they defined as catastrophic medical bills that exceeded half of your annual income. They found big improvements in people saying they could access medical care. They used more medical care, they had better self-reported health. They had lower depression.
Sarah Miller: The area of that study, I think that was a little incomplete, was on the mortality side, since it was only 10,000 people, and we talked a little bit in the slides about how mortality is fortunately pretty rare among working age adults. And so it looked in. If you look at their tables, it looked like Medicaid reduced mortality, but it just wasn't considered statistically significant. But actually it looked, you know, the effects that they were getting actually looked pretty similar to what later studies found.
Sarah Miller: So I would say, the Oregon health insurance experiments just a terrific one to look at the Irs experiment that was done where they mailed people nudging them, saying, Hey.
Sarah Miller: you know you may be eligible. Sign up. If you don't sign up, you might be subject to a penalty. That was a great experiment, because they, you know, unlike the Oregon experiment, which had 10,000 people. They had like millions of people in the experiment, so they could easily find. You know they had amazing statistical power, and they found significant improvements in mortality. I think that's a great one.
Sarah Miller: I talked about my study where we looked at mortality rates from the Aca expansions. But there was another study done by a different team that basically had a bigger data set than we had and did the same sort of analysis, but because they had a bigger data set, they could look at
Sarah Miller: these like small subgroups like, is it different for women and men, and look at different, just kind of really dig into it. One reason I really like that as a scientist is, you know, you might sometimes hear about like the replication crisis. It's always good. If you can get a totally independent 3rd party to try to do the analysis themselves and see what they find. I think you can really take papers to the bank, that
Sarah Miller: where that's the case where you can. It's not just one team saying, this is what we find. But again, we totally non overlapping team? They weren't our Co. Authors on the original paper. You know, we're able to replicate it. So that's a really nice paper to look at as well, so.
Adam Searing: Okay. Great that. Thank you. Those those are great ideas, and that this I'm gonna turn it over to Natalie in just a sec for a couple more questions, but and then we're gonna finish. But I'm wondering if, when, if we could share, if you have it easily available and bibliography of some of these.
Sarah Miller: Yeah.
Adam Searing: All the stuff that's in your slides and everything because we would love to be able to share that with you know. And and if you could put the one those 3 that you talked about at the top, because.
Sarah Miller: Sure thing.
Adam Searing: I love that your response to that that was great, you know, because those are the kinds of things that I think when people are having these real world conversations, they can say, Look, this is really good research, you know, we should really look at that. And that improves the. You know we live in a terrible time for having solemn, you know, serious discussions about policy. But we're trying to. So you know. All right, Natalie, I'm gonna pass it back over to you.
Natalie Lawson: Sure. Yeah, we got another question about, why is there so much diversity within managed care plans? And I think maybe we could expand on that question as well, and say, like, what is managed? Care like to grapple with in your research? Right like, how is how does managed care, and the all the variety of plans that exist affect what you're able to look at as a researcher.
Sarah Miller: Yeah, I I think that's a that's a great question. And I would say, you know we don't.
Sarah Miller: We don't totally know why some managed care. Plans seem to be more successful than others. Part of it definitely seems to be related to network, and part of it seems to be related to like what fraction of expenses are going towards medical care versus going to overhead. So I mean, I think there's some very crude
Sarah Miller: things that you can say, like, obviously, if you're spending more money on medical care versus on sort of other things that maybe beneficiaries really like, but don't improve health as much that that's probably going to be predictive of how successful you are. At the same time, you know, beneficiaries usually get to choose their managed care plan. And so
Sarah Miller: please don't always have an incentive to spend money on the more boring things versus advertising for things that might be more appealing to beneficiaries. So I think there's a challenge there, I'd say, in terms of my research.
Sarah Miller: you know, part of the challenge is, we try to get at like a
Sarah Miller: effective Medicaid. You know, we try to say, Oh, this is the. This is the effect of the expansions, right? But really you have
Sarah Miller: lots of different effects. And they might, you know, typically they're like not too different, we would hope, but they might differ a bit from state to state, or even within a state, from plan to plan because they're just. It's it's not one program. It's a 50 state program, right? It's a Federal State partnership.
Sarah Miller: And yeah, the old saying is like, you know, if you've seen one Medicaid program, you've seen one Medicaid program, right? It's the joke that the health services researchers always like to make. So I think, just grappling with how to understand that heterogeneity is something that's challenging for researchers.
Sarah Miller: And there's also heterogeneity, not just across the plans. But in who's getting it. There might be some people who benefit a lot more than other people. And when you're just taking an average, you're kind of losing that those kind of subtleties. So
Sarah Miller: I'd say that that can be challenging for researchers to really PIN down and understand.
Natalie Lawson: Yeah, well, thank you so much. Adam, if do you have anything else, Adam? Otherwise I can go ahead and wrap us up if you'd like.
Adam Searing: Go, go ahead and wrap us up.
Natalie Lawson: Sure.
Adam Searing: We'll say, Thank you so much. Dr. Miller. Yeah, yeah.
Sarah Miller: My pleasure. Thanks so much for having me.
Adam Searing: Yeah.
Natalie Lawson: I really appreciate it, Dr. Miller, and just one more quick wrap up. A reminder is that we have another webinar next week on provider taxes in Medicaid, how States use them, and the budgetary effects of proposed Federal changes, and that's going to be next Wednesday. So April 23, rd at 3 Pm. Eastern, so we hope to see you there once again. Thanks, Dr. Miller, and thanks everybody.
Adam Searing: Yeah, thanks for coming, everybody.
Adam Searing: Alright, bye, thanks again.