WASHINGTON - The decision by 25 states to reject the expansion of Medicaid coverage under the Affordable Care Act will result in between 7,115 and 17,104 more deaths than had all states opted in, according to researchers at Harvard Medical School and the City University of New York.

The study, the first detailed estimate of the health impact of the states’ decision to reject the Medicaid expansion (with state-by-state data as well), is being published today at the Health Affairs Blog.

The researchers found that because of the states’ “opting out” of the Medicaid expansion, 7.78 million people who would have gained coverage will remain uninsured. In addition to the thousands of excess deaths associated with that lack of coverage, the rejection of the Medicaid expansion will have the following likely impacts:

* 712,037 more persons diagnosed with depression
* 240,700 more persons suffering catastrophic medical expenses
* 422,533 fewer diabetics receiving medication
* 195,492 fewer women receiving mammograms and
* 443,677 fewer women receiving pap smears

“We calculated the number and characteristics of people who will remain uninsured as a result of their state’s opting out of the Medicaid expansion, and applied these figures to the known effects of insurance expansion from prior studies,” said Samuel Dickman, a third-year medical student at Harvard Medical School and the study’s lead author. “The results were sobering. Political decisions have consequences, some of them lethal.”

Dickman and his colleagues, longtime health researchers at Harvard Medical School and the City University of New York, drew on demographic data from the Census Bureau’s 2013 Current Population Survey and estimates on Medicaid take-up rates from the Congressional Budget Office and elsewhere to characterize those who would remain uninsured in states opting out of Medicaid expansion.

They developed estimates of the health effects of remaining uninsured based on previous studies that used state-level data on Medicaid expansions and death rates, the National Health and Nutrition Examination Survey Mortality Follow-up, and the Oregon Health Insurance Experiment.

In addition to arriving at national estimates, the researchers were able to break the findings down by state.

For example, in Texas, the largest state opting out of the Medicaid expansion, approximately 2 million people who would otherwise have been insured will remain uninsured as a result of the state’s action.

"Texas' refusal to accept federal money to expand Medicaid will result in 184,192 more people experiencing depression, 62,610 more people suffering catastrophic medical expenses, and as many as 3,035 avoidable deaths,” said Dr. Steffie Woolhandler, a professor of public health at the City University of New York who is also on the faculty at Harvard Medical School.

The study includes a table showing expected excess deaths and other harms from opting out of the Medicaid expansion on a state-by-state basis.

“Medicaid is far from perfect,” said Dr. David Himmelstein, who also teaches at CUNY and Harvard. “In many parts of the country Medicaid pays so little that patients have trouble finding a doctor who will accept it. A single-payer program like Canada’s that covers all Americans is a far better solution for both the poor and the middle class. But until we get to single payer, Medicaid is the only safety net for many low-income Americans.”

Woolhandler and Himmelstein are also co-founders of Physicians for a National Health Program, a nonprofit research and education organization of more than 18,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study.

A link to the study at the Health Affairs Blog is available here.