The New York Times published an article describing Maine Gov. Paul LePage’s refusal to expand Medicaid in that state through Obamacare. LePage’s refusal defies a binding vote on a 2017 ballot initiative, when the state’s voters approved expanding the program.
The New York Times frames the refusal as both unwarranted legal malfeasance and as an assault on Maine residents’ health just to save money for taxpayers. This framing is not completely inaccurate. Directly defying the state’s voters is certainly unusual. On the budgetary front, the governor has repeatedly stated that the state needs to find the necessary funds (approximately $60 million annually) from sources other than new taxes or dipping into the state’s reserves.
But neither is the article framing complete. It leaves out relevant details about the expected health benefits, which distort readers’ understanding.
Here’s the Rest of the Story
The impression The New York Times leaves is of a leader indifferent to his citizens’ health. The implicit assumption is that expanding Medicaid is an unalloyed good for Maine, and only base or corrupt motives could explain not doing it. The Times expends no effort in examining the basis for that assumption. This is unfortunate, as there is a clear empirical correlation between expanding Medicaid and increased mortality.
To date, there is no generally accepted causation mechanism between expanding Medicaid under ObamaCare and the increase in the death rate, but the correlation is clear and unambiguous. Some have proposed a link between the increased mortality and an increase in opioid deaths due to Medicaid expansion. The U.S. Senate held a hearing on the subject and issued a report. The Medicaid-opioid link has not been accepted by public health academics so far, but neither have they proposed a convincing alternate explanation for the empirical connection between Medicaid and increased mortality rates.
Even without knowing the cause of the link between Medicaid and increased death rates, it is clear that the relationship exists. Therefore, it is possible that LePage, intentionally or unintentionally, is actually preserving the lives of his fellow citizens in the Pine Tree State. But one would never know this from reading The New York Times.
Let’s Compare Maine to New Hampshire
How much is LePage helping the residents of Maine? We can estimate the magnitude of the correlation between Medicaid and increased death by comparing Maine to its next-door neighbor.
New Hampshire expanded Medicaid in accordance with Obamacare immediately after the law was implemented in 2014. The two states are similar in many respects, with nearly identical populations, and relatively large rural populations.
New Hampshire is somewhat more urbanized than Maine, and wealthier, as one would expect from its proximity to Boston, which leads to better general health outcomes. However, the two states’ demographics are very alike, and their health trends have correlated well over the past several decades.
Mortality statistics for the two states can be generated from the Centers for Disease Control (CDC) WONDER database, which uses the ICD-10 codes from 1999 through the latest data collected in 2016. The results of this comparison are shown in Figure 1.
Figure 1: 1999-2016 time series of Maine and New Hampshire death rates, from all causes.
Both states experienced a large increase in the mortality rate after implementing Obamacare. This was a nationwide trend, so the data from Maine and New Hampshire are not surprising. However, the difference in the rate of increase between Maine and New Hampshire is significant.
Prior to Obamacare, the 18- to 64-year-old all-cause death rate in Maine averaged 319 deaths per 100,000 in population (1999 – 2013 mean = 319.4; σ = 15.8). The mortality rate was trending upward at a rate of about 3.2 deaths per 100,000 per year. Subsequent to Obamacare implementation, the Maine death rate between 2014 and 2016 mean increased to 365.6 deaths per 100,000, a 2.9 σ increase.
While the Maine trends are a terrible window into the worsening health situation in that state, they look positively benign compared to the grim data from New Hampshire. Prior to Obamacare, the 18- to 64-year-old all-cause death rate in New Hampshire averaged 270 deaths per 100,000 in population (1999 – 2013 mean = 269.8; σ = 12.0).
The mortality rate was trending upward at a lower rate than Maine, about 2.4 deaths per 100,000 per year. But after implementing Obamacare, the New Hampshire death rate 2014 to 2016 mean increased to 329.3 deaths per 100,000, a 5.0 σ increase. The 2013 to 2016 death rate trend in New Hampshire is skyrocketing upward by 18.8 deaths per 100,000 per year.
In Maine, the mean death rate increased an awful 14 percent after Obamacare went into place, but the New Hampshire mean rate increased a truly catastrophic 22 percent. While New Hampshire had approximately 84 percent of the death rate of Maine from 1999 to 2013, this increased to more than 90 percent of the Maine death rate after ObamaCare and Medicaid expansion was implemented in New Hampshire.
It is easy to approximate the differential deaths New Hampshire suffered. If the mean death rate increase in New Hampshire had been limited to 14 percent in that state after ObamaCare, as was the case in Maine, the mean rate would have been 309 per 100,000 from 2014 to 2016. More than 500 Granite Staters died in those three years, who, statistically speaking, would still be alive today if New Hampshire’s mortality trend matched that of Maine.
In short, after fully implementing Obamacare, including the Medicaid expansion, New Hampshire residents have died in desperately large numbers, far in excess of the neighboring state, whose governor refused to expand Medicaid. New Hampshire’s state motto has never seemed so dreadfully and literally accurate.
Is Governor LePage a Hero?
The correlation of Obamacare’s Medicaid expansion to increased mortality is not limited to New Hampshire. The overall national trend confirms that states expanding Medicaid have increased mortality relative to states that refused to expand Medicaid.
One would never know this from reading The New York Times, but LePage’s refusal to expand the program in Maine is firmly correlated with 500 fewer deaths in that state between 2014 and 2016 than Medicaid expansion trends would indicate.
Since causality between Medicaid expansion and increased mortality has not yet been proven, it is impossible to say that LePage has definitively saved these lives, but it is accurate to state that his actions are consistent with the best available information to improve the health of his fellow Mainers. Even if this were not the case, it is extraordinarily churlish of The New York Times to imply that LePage doesn’t care about the health of the citizens of the state he governs.
Further Ramifications of This Data
Idaho, Nebraska, and Utah all have initiatives on the November ballot to expand Medicaid, similar to the one passed in Maine in 2017. The citizens of these states need to be aware of the correlation between Medicaid expansion and increased mortality. They need to understand that a vote in favor of expanding Medicaid does not guarantee improved health of their fellow citizens and there is, in fact, a real possibility it may seriously harm them.
In Maine, the state government needs to examine the mortality data from New Hampshire and other states that have expanded Medicaid to determine if there are certain causes of death, such as drug overdoses, that are more likely after expansion. Then, if the legal system directs LePage to implement the Medicaid expansion, his administration may have the information needed to do so while limiting some of the factors leading to increased mortality.
All across America, citizens need to understand that Medicaid, as best as can be determined from available studies and data, does not seem to be effectively improving the health of America’s poor and needy. The program desperately requires reform and improvement, which cannot simply consist of more money and expansions. Once the true facts are understood, we can better understand Medicaid’s benefits and weaknesses. Let the discussion begin.