KANSAS CITY — While some studies have found that Medicaid expansion reduces overall mortality rates in states where it has been adopted, a recent study published in the Journal of Rural Health looks more closely at mortality rates in specific populations. This study points to complex factors that may affect mortality differently depending on race, ethnicity, sex and geography.
Looking across the nation using data from states that have expanded Medicaid with federal money, the study indicates many different factors at play.
“The primary takeaway is that Medicaid expansion is unevenly impacting all-cause mortality nationwide,” said J. Tom Mueller, Ph.D., assistant professor in the Department of Population Health at the University of Kansas Medical Center and primary author of the study. “Rural populations are seeing clear negative impacts, and urban populations are seeing only some benefits.”
Mueller is a rural sociologist and demographer focused on inequality, health and well-being in rural America. He focuses on issues of social policy and the environment, attempting to understand why some places have persistently lower health and well-being than others, and what can be done to change that for the better. He came to KU Medical Center from the University of Oklahoma in 2023.
The purpose of this study was to drill down into data to see how different groups fared when their state expanded Medicaid. Mueller noted that these impacts were uneven across ethnic and racial groups, with rural white populations seeing the clearest negative impacts and urban Black populations seeing the greatest evidence of health improvement.
The study showed that Medicaid expansion led to a reduction in all-cause age-adjusted mortality for urban Black populations, but not rural Black populations. Urban white populations experienced mixed effects depending on how many years had passed since Medicaid expansion. Latino populations saw no appreciable impact. While no effect was observed for rural Black and Latino populations, rural white all-cause age-adjusted mortality unexpectedly increased due to Medicaid expansion. These effects reduced rural- and urban-specific mortality disparities among Black and white populations but did not shrink the rural-urban mortality gap.
“To be clear, this does not mean expanding Medicaid is foolhardy or misguided — there is a lot of evidence that it has led to a great number of health improvements nationwide,” Mueller said. “What this means is that the rural health care system, which is already struggling and has long been facing issues of funding, resources and personnel, is not providing rural Americans on Medicaid with the safe and effective health care they need.”
Mueller and his research colleagues from the University of North Carolina at Chapel Hill and Florida State University were surprised by the outcome of the study, but Mueller believes it points toward a complex range of issues facing rural Americans.
“Opioid prescribing is higher in rural areas and among Medicaid patients, and chronic pain is far more common in these areas,” Mueller said. “Our ongoing follow-up research suggests that drug overdoses are driving the increase in all-cause mortality, so the picture is starting to come together, but we were neither hoping nor expecting to find this negative outcome for rural Americans.”
Mueller noted that additional research of the complex issues is underway by his team: “We are already studying the impact of Medicaid by cause of death and age group to identify what is driving the increase in all-cause mortality.” He pointed out that the increase in mortality seems largely due to drug overdoses, although there may be some correlations to diseases known to impact rural areas, such as chronic respiratory disease, heart disease and stroke. Another issue affecting rural mortality is the lack of access to health care providers, including a shortage of those who accept Medicaid. Mueller and his research colleagues already are studying these shortages.
“Rural areas have lost many health care services, and many doctors either don’t accept Medicaid at all, or are unwilling to accept new patients. In a rural area with few substitutes, if your local clinic won’t accept Medicaid, you could have a truly difficult time finding care,” Mueller said.
“It is imperative that resources and attention be directed to rural areas to ensure that Medicaid expansion actually results in patients seeing doctors and receiving effective and safe care.”