Person:

Gordon, Sarah

Twenty-five states and Washington D.C. are expanding Medicaid in 2014 under the Affordable Care Act. We surveyed Medicaid directors in expanding states to assess expectations and implementation strategies regarding enrollment, costs, and access. Telephone interviews were conducted between July and November 2013, with most occurring before open enrollment began October 1. The response rate was 88%. Overall, expectations were a mixture of optimism and caution. Predicted enrollment was high: 86% of officials projected at least 50% participation among newly-eligible uninsured adults. Officials predicted most Medicaid applications will come via statebased Exchanges (32%), navigators (23%), or directly to Medicaid (45%); none thought Healthcare.gov would be the primary means of Medicaid enrollment. Over 95% think expanded coverage will improve beneficiaries’ health care and health. 57% expect the expansion to produce state savings; however, 29% expect net costs to their state over the next decade. 73% viewed it as “possible” or “likely” that the federal government will reduce the federal share of costs due to budget pressures. Lack of specialists accepting Medicaid (50%) and coverage churning (45%) were described as the most likely potential barriers to care. States are taking a range of approaches to facilitate enrollment and promote continuity of coverage between Medicaid and Exchanges.

Prior studies suggest that higher unemployment rates reduce mortality, but newer research suggests this relationship may have attenuated in recent decades. Moreover, individual-level evidence shows a negative effect of economic adversity on survival. We revisit this question using county-level data and two additional macroeconomic measures: poverty rates and median incomes. Examining county-level mortality among non-elderly adults from 1993-2012, we find that higher unemployment has modest negative impacts on mortality, in contrast to prior work using older state-level data. More notably, county-level poverty rates and lower median incomes produce larger and consistently negative effects on mortality, both in the short-term and also for several years afterwards. These findings are consistent across multiple causes of death and for different subgroups of adults. While previous research has found that higher unemployment may produce small beneficial effects on survival, our analysis using more recent and granular data suggests this relationship no longer holds, and other economic measures such as median income and poverty rates provide stronger evidence that adverse economic conditions lead to higher mortality.