Mortality and morbidity ramifications of proposed retractions in healthcare coverage for the United States

Significance

Medicare and Medicaid are crucial programs in the United States that ensure that the elderly, low-income individuals and those with disabilities can access medical services. While the unwinding of continuous enrollment provision for Medicaid is already underway, some other changes such as raising the Medicare eligibility age and implementing work requirements for Medicaid have been proposed. These changes are primarily argued in economic terms. However, we evaluate their impact on public health, encompassing both increased mortality and morbidity resulting from these modifications. We find that the health loss greatly outweighs the federal value for a statistical life. 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.

Abstract

In the absence of universal healthcare in the United States, federal programs of Medicaid and Medicare are vital to providing healthcare coverage for low-income households and elderly individuals, respectively. However, both programs are under threat, with either enacted or proposed retractions. Specifically, raising Medicare age eligibility and the addition of work requirements for Medicaid qualification have been proposed, while termination of continuous enrollment for Medicaid was recently effectuated. Here, we assess the potential impact on mortality and morbidity resulting from these policy changes. Our findings indicate that the policy change to Medicare would lead to over 17,000 additional deaths among individuals aged 65 to 67 and those to Medicaid would lead to more than 8,000 deaths among those under the age of 65. To illustrate the implications for morbidity, we further consider a case study among those people with diabetes who would be likely to lose their health insurance under the policy changes. We project that these insurance retractions would lead to the loss of coverage for over 700,000 individuals with diabetes, including more than 200,000 who rely on insulin.

While the United States (US) stands alone among high-income nations in failing to guarantee healthcare for all, the federal programs Medicare and Medicaid offer essential lifelines for the elderly and those in poverty. These programs ensure healthcare access for many people who would not otherwise have access. Alarmingly, recent changes or proposals to make eligibility requirements more stringent, jeopardize this vital access for millions of Americans.

Medicare is a federal health insurance program that provides coverage for individuals aged 65 and above. Given that many Americans depend on their employer for healthcare coverage, Medicare is essential for individuals in retirement. Since its establishment in 1965, Medicare has been crucial for improving healthcare quality for seniors and individuals with disabilities by offering affordable healthcare coverage. However, an increase in the Medicare eligibility age has been proposed several times as a means to reduce Medicare costs (1, 2). A recent report from the congressional Republican Study Committee specifically recommended changing the eligibility age from 65 to 67 y (3). Raising the eligibility age is bound to impede access to reliable healthcare for seniors across the country.

Moreover, ramifications of these changes may be more dramatic in some regions of the United States than others. For example, residents of McDowell County, West Virginia, have grappled with the economic fallout from local mine closures (4). Approximately one in three county residents live in poverty, and over one in five individuals under the age of 65 live with a disability (5). Many individuals, including former coal miners who face unemployment and those working part-time jobs, have transitioned from a system of generous employer benefits to navigating a labyrinthine and resource-constrained system in order to maintain even basic healthcare access. Enrollment in Medicare at the age of 65 represents not just a change in insurance status but a crucial bridge to stable and affordable healthcare. Medicare’s role also extends beyond healthcare access, contributing to economic stability as out-of-pocket healthcare expenditures are reduced by one-third for those with Medicare coverage (6).

However, if the eligibility age for Medicare is increased to 67 y, many individuals face the risk of being uninsured for a longer period, risking both their physical and economic health. According to estimates from the Congressional Budget Office (CBO), raising the Medicare eligibility age would result in a 15% uninsurance rate among the affected population aged 65 to 67 y (7). Being uninsured in the United States is associated with a 40% higher risk of death compared to insured individuals of the same age (8). The reasons for this are manifold. Individuals without insurance often do not have a relationship with a primary care provider. A relationship of trust with a provider is fundamental to the uptake of preventative measures even when those measures are subsidized by federal and local governments, such as with the COVID-19 vaccine (9). Furthermore, the uninsured are more inclined to delay care until a health condition has progressed to an advanced stage, at which point the risk of morbidity and mortality is greater. For example, individuals without insurance are less likely to be treated for cancer at an early stage (10). Managing chronic health conditions for uninsured individuals is particularly challenging. Without the financial safety net of health insurance, these individuals often delay or forgo essential medical treatments, prescriptions, and preventative care due to cost concerns, exacerbating the risk of complications (11). Despite bearing a disproportionate burden of chronic conditions, uninsured individuals are more likely to have an undiagnosed disease, and if diagnosed, less likely to have it well-managed (12).

Applying the elevated rates of mortality to those individuals between 65 and 67 who would lose their healthcare access (Methods and SI Appendix, Material), we estimate that 9,646 [95% uncertainty interval (UI): 1,908 to 20,827] additional lives would be lost annually, compared to the status quo. However, the proponents of the policy change focus on the fiscal deficit, but do not consider the mortality repercussions. The CBO has analyzed two transitional strategies for raising the Medicare eligibility age to 67. The first proposed strategy involves increasing the eligibility age by 2 mo each year, starting in 2023 and continuing until it reaches 67. According to the CBO estimates, this approach would reduce the fiscal deficit by ~15.4 billion from 2023 to 2028 (7). The second strategy would increase the Medicare eligibility age by 3 mo each year, which is projected to decrease the fiscal deficit by ~21.8 billion between 2023 and 2028 (7). Our projections indicate that implementing these approaches would result in an additional 17,244 (95% UI: 3,603 to 37,230) and 25,847 (95% UI: 5,401 to 55,804) deaths, respectively, between 2023 and 2028 (Table 1). The federal cost savings would be ~893,000 per life lost and ~843,400 per life lost, respectively. These savings are much lower than the ~12.5 million value of a statistical life previously used for policy decisions by the federal government (13).

Table 1.

Excess death resulting from delaying Medicare eligibility age

Year	CBO strategies to raise Medicare eligibility age (MEA)
	Raising MEA to 67 by 2 mo each year			Raising MEA to 67 by 3 mo each year
	Lives lost		Deficit reduction (billions of dollars)	Lives lost		Deficit reduction (billions of dollars)
	Median	95% UI		Median	95% UI
2023	811	160–1,751	0.7	1,216	241–2,626	0.8
2024	1,625	322–3,509	1.4	2,438	482–5,263	1.8
2025	2,513	497–5,425	2.1	3,769	746–8,138	2.8
2026	3,314	656–7,155	2.8	4,971	983–10,733	4.0
2027	4,083	808–8,815	3.6	6,130	1,213–13,234	5.2
2028	4,898	969–10,575	4.8	7,323	1,449–15,811	7.1
Total	17,244	3,603–37,230	15.4	25,847	5,401–55,804	21.8

Breaking down by state and jurisdiction, the geographic distribution of the 17,244 additional deaths from implementing the first strategy would range from 26 in the District of Columbia to 1856 in California. Along with California, three other states are expected to experience more than a thousand additional deaths: Texas, Florida, and New York. Per capita, additional deaths per one million capita would range from 19 in Utah to 33 in Maine (Fig. 1).

Fig. 1.

State-level mortality implications of raising eligibility criteria for Medicare to 67. Distribution of excess death between 2023 and 2028 if the eligibility criteria are raised by two months each year beginning in 2023 (Top). Additional deaths per ten thousand population (Bottom).

While Medicare is provided by the federal government to all seniors, states typically contribute a proportion of the Medicaid funding for their low-income constituents. Consequently, Medicaid eligibility criteria vary by state. Thresholds can be as low as the federal poverty line of ~14,580 for annual income (14) and ~2,000 in assets (15). Eligibility verification and renewal are often onerous, and a significant proportion of eligible people remain unenrolled (16).

To preserve healthcare coverage for low-income families during the COVID-19 pandemic, the Medicaid Continuous Enrollment Provision was authorized by Congress in 2020. The provision mandated states to uphold coverage for existing Medicaid enrollees without requiring additional verifications. However, the continuous enrollment provision ended on March 31, 2023 (17). Subsequently, states have begun disenrolling those who are no longer eligible or who are unable to complete the renewal process.

The redetermination process has become a challenge for many, disproportionately so for those in rural areas due to lower educational attainment (18), and lack of reliable internet access (19). This combination means that even eligible individuals are at risk of losing coverage, and indeed by November 2023, 71% of disenrollments were due to procedural reasons (20). In some states such as Utah and New Mexico, more than 90% of disenrollments thus far have been due to procedural reasons (20).

Given the varying implementation approaches by states, the full impact of terminating continuous Medicaid enrollment remains uncertain (21). However, the CBO estimates that approximately 15.5 million people below the age of 65 will lose Medicaid coverage (22). Of this total, it is expected that 9.3 million people will be able to transition to another form of coverage, but that 6.2 million will become uninsured (22). If the age distribution of those who will lose their insurance is similar to that for the currently uninsured, we estimate that terminating continuous enrollment will result in 7,900 (95% UI: 1613 to 16,339) additional deaths, of which 40.3% (95% UI: 40 to 40.8%) will be among those aged 55 to 64 (Table 2).

Table 2.

Mortality and morbidity implications for individuals who will be uninsured after losing Medicaid due to retraction of enrollment duration

Age-group	Metric
	Additional deaths		Living with diabetes
	Median	95% UI	Median	95% UI
<25	327	66–688	6,069	5,920–6,238
25–34	1,064	220–2,161	74,308	61,755–91,157
35–44	1,383	285–2,825	60,204	50,192–73,591
45–54	1,939	397–3,998	178,443	153,857–210,174
55–64	3,187	645–6,665	137,943	118,694–162,847
Total	7,900	1,613–16,339	456,966	390,417–544,006

Work requirements for Medicaid recipients are a perennial proposal in federal budget negotiations (23), most recently via the Limit, Save, Grow Act of 2023 (24). Work requirements add both another obstacle and another layer of bureaucracy for low-income people seeking healthcare access. The CBO estimates that if work requirements are implemented, 600,000 current Medicaid enrollees would become uninsured (24). We calculate that this loss of coverage would lead to additional 613 (95% UI: 163 to 838): deaths among individuals aged 19 to 54.

Beyond mortality, these policy changes also affect quality of life and the morbidity of ill health. Chronic diseases such as diabetes, heart diseases, and HIV necessitate primary healthcare for swift diagnosis as well as consistent care to mitigate progression to advanced stages. For example, complications of untreated diabetes include retinopathy, nerve damage, cardiovascular diseases, and kidney damage (25). To project the extent to which these policy retractions would specifically impact individuals with diabetes, we estimated the diabetes prevalence among the individuals losing access to care. Applying the age distribution of diabetes in the United States (26), we found that a staggering 456,966 (95% UI: 390,417 to 544,006) people with diabetes who are under the age of 65 would lose access to vital primary care services after the unwinding of Medicaid’s continuous enrollment provision (Table 2). Additionally, an estimated 325,613 (95% UI: 296,413 to 361,216) seniors aged 65 to 67 diagnosed with diabetes would lose access to healthcare services if Medicare eligibility age were revised. The consequences of this could manifest as untreated diabetes, higher prevalence of diabetic complications, and a reduced quality of life for those affected. 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 (26, 27).

Across the United States, our state-specific analysis reveals considerable geographic heterogeneity in the ramifications of healthcare retractions for seniors with diabetes (Fig. 2). Mississippi, West Virginia, Louisiana, and Alabama are among the states in the United States with the highest prevalence of diabetes (28), and if the eligibility age for Medicare were to be increased, individuals aged 65 to 67 living with diabetes in these states would experience the gravest per capita loss of healthcare. Consequently, these proposed policy changes are likely to intensify the public health challenges with which these states are already grappling.

Fig. 2.

Per capita state-level distribution of individuals aged 65 to 67 y living with diagnosed diabetes who will lose access to care if eligibility age for Medicare is raised to 67 y.

Presently, 31% of individuals managing diabetes rely on insulin (29). In the United States, insulin prices surged by more than 200% between 2007 and 2018 (30). One-fifth of all Medicare beneficiaries with diabetes already spend more than 40% of their postsubsistence income on insulin (31). The rising costs of insulin, coupled with high deductibles and copays under employer-sponsored insurance coverage, have led many to resort to rationing their insulin, often with serious health consequences (32). Uninsured individuals have the highest rates of insulin rationing (32), with nearly a third of uninsured individuals rationing their insulin.

As a result of potential changes to Medicare and Medicaid eligibility criteria, we estimate that 242,600 (95% UI: 212,917 to 280,619) people dependent on insulin would lose their health insurance. More than 40% (41.6%, 95% UI: 39.9 to 43.2%) of them would be seniors aged 65 to 67, corresponding to 100,940 (95% UI: 91,888 to 111,977) individuals. The proposed policy change would therefore exacerbate what is already a crisis for many seniors.

While we assessed the mortality and morbidity implications specifically for those people losing access to care, the detrimental impact of these policies would ripple throughout the entire healthcare system and to society at large. In addition to the individuals who would lose their insurance as a result of delaying the eligibility age for Medicare, others would likely seek coverage through their employers, purchase it directly, or rely on Medicaid. For these people, the Medicare policy retraction may merely shift the cost from the federal government to employers, state governments, and society who will all incur higher healthcare costs. This shift would be particularly inefficient since Medicare delivers healthcare at a lower per capita cost than these other programs (33). While advocates for increasing the eligibility age argue that Americans are living longer, it is critical to also consider that compared to previous generations, older adults are more likely to suffer from multiple chronic illnesses that may affect their ability to work (34). Additionally, continuing to work in certain professions at an older age may be detrimental to health and compound underlying health conditions. Among those who lose Medicaid enrollment due to changes in qualification criteria, many are expected to obtain insurance in the private market, and this group is 44% likely to be underinsured (35). Underinsurance is defined by the inability to afford necessary healthcare, which contributes to the delay of important care. Our analysis is therefore conservative with regard to the harm that would arise from these policies, as we only account for increased mortality and morbidity among those who become uninsured, and do not consider these higher costs elsewhere in the system or their health impact.

To calculate the additional mortality, we used the hazard ratio of death among uninsured individuals compared to insured individuals. This hazard ratio was estimated based on mortality among people aged 17 to 64 (8). While there has been no study quantifying the likelihood of death between uninsured and insured individuals who are 65 or older, a study focusing on individuals between the ages 55 to 64 (36) found a hazard ratio for this near elderly population that aligns with that of the wider 17 to 64 age group (8). Therefore, extending the same hazard ratio to include individuals aged 65 to 67 y is a plausible assumption. Moreover, the hazard ratio utilized in our assessments is based on data spanning 1988 to 2000, and the US population has become both older and more diverse since that time. However, the study adjusted for many demographic characteristics that may change over time including age, gender, race, income, and educational qualifications (8). Therefore, while absolute mortality rates may change over time due to shifts in the underlying population, the hazard ratio itself is likely to remain robust.

The mortality and morbidity burden we estimate would likely exacerbate existing inequities. Enrollment in Medicaid is predicated on low income, and individuals from underserved racial and ethnic groups make up a significant fraction of enrollees. Barriers to enrollment will disproportionately harm these populations. With regard to Medicaid eligibility changes, low-income individuals, those with disabilities, and members of underserved racial and ethnic groups are among those who have inadequate levels of insurance coverage prior to age 65. Therefore, raising the Medicare eligibility age will prolong their restricted access to care. Moreover, health disparities often manifest at earlier ages for vulnerable populations. Consequently, these at-risk communities will bear an undue burden of the annual lives lost and untreated chronic conditions attributable to these policy changes.

Medicare has been a reliable safety net for elderly Americans for many years. Similarly, Medicaid has provided healthcare services to millions of Americans and reduced their financial burden. Therefore, any changes to these programs must weigh questionable cost-savings against the impact on America’s health and well-being. Our findings indicate that increasing the eligibility age for Medicare would be a step backward. Furthermore, revising the Medicaid qualification process following the discontinuation of continuous enrollment policies and imposing work requirements for Medicaid access both have adverse effects on Americans’ ability to access healthcare. For policymakers who are justifiably concerned about the magnitude of healthcare spending in the United States, which far exceeds any other high-income country (37), the cost reductions from adjusting these programs should be compared against other options for healthcare reform. For instance, single-payer universal healthcare has been shown to save more than ~400 billion annually and would save 68,000 lives (33, 38). By contrast raising Medicare eligibility would save a maximum of ~25.5 billion across 5 y (7) at a loss of over 17,000 lives. Instead of adopting policies that would further erode the quality of American healthcare, it is essential to strengthen and enhance Medicare and Medicaid programs to expand their benefits, saving money and lives.

Methods

We evaluated the mortality consequences of three recently proposed or implemented retractions of healthcare coverage. Being uninsured in the United States is associated with a 40% higher risk of death in comparison to individuals of the same age who are insured (8). To update the insurance status for the impacted population, we used estimates of the number of individuals expected to become uninsured following the implementation of the respective policies (7, 22, 24). By incorporating the heightened risk of mortality (8) among those who lose their insurance, we calculate the expected number of deaths that the impacted population would experience post implementation of the policy (SI Appendix, Material). We then derive the additional deaths resulting from the policy by computing the difference between this expected mortality count with the current mortality count within the affected age cohorts (39). For our assessment of change in Medicare eligibility criteria, we conduct a state-level analysis. In our evaluation of Medicaid policy revisions, we incorporated the demographic stratification of recipients (40). We also illustrate the morbidity impact of these policy changes with diabetes as a case study. Specifically, we apply age-distributed prevalence of diabetes in the United States (26) to estimate the number of individuals with diabetes among those who are expected to lose health insurance due to these policy changes.

Supplementary Material

Appendix 01 (PDF)

Data, Materials, and Software Availability

All study data are included in the article and/or SI Appendix.