As policy makers have debated proposed Medicaid cuts this summer, Marc Cohen and Jane Tavares have been busy researching and writing. Cohen and Tavares, both with the LeadingAge LTSS Center @UMass Boston, a part of the Gerontology Institute, have dived into data to explore what these potential cuts may mean to older adults. Supported by the RRF Foundation for Aging, they’ve analyzed trusted sources of information to help people, including policymakers, advocates, and regular Americans, understand how these potential cuts stand to affect vulnerable older adults.

“As a research center, our role is to produce research that informs the policy and practice debate,” Cohen says. “Our research and analysis looking at the implications of policy changes is often used by advocates to put forward a more effective case based on empirical data and evidence. And this is as it should be given that the LTSS Center’s tagline is, ‘Research bridging policy and practice;’ this work is in direct service to that mission.”

Their work has had quite a reach. One story, Why Do Cuts to Medicaid Matter for Americans Over 65?, has already been read more than 100,000 times, after being reprinted in outlets such as the Philadelphia Inquirer and Katie Couric Media. Their research has been cited by Newsweek, NPR, and Scientific American.

Here, Cohen and Tavares explain the importance of this analysis and how they hope it informs the debate:

Q: You both have had several pieces published recently about the potential effects that Medicaid cuts could have on older adults. Why is this an important topic for the LeadingAge LTSS Center to address?

Cohen: How the healthcare system is financed drives so much of what the LTSS Center is trying to accomplish, which is to improve the lives of vulnerable older adults as they age. The biggest public financer of services is Medicaid. We have an obligation to bring empirical data and evidence to support the policy debate in two ways: first, to help policymakers make more informed decisions, and second, to ensure that people cannot easily hide behind falsehoods and distortions. For example, when policymakers say that they’re not taking money away from Medicaid or changing the program—that these changes only affect people who aren’t working or contributing to society—we help lay bare how false and distorted that claim is.

We want people to age in place with dignity. We want to support the health of the American people, and these proposed cuts are curtailing people’s ability to pay for health care. Martin Luther King, Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” He believed that healthcare is a fundamental human right and to deny it, especially on the basis of race or economic status, is a particularly egregious form of injustice.  I wholeheartedly agree with him, as does Jane, and so we feel obligated to push back against this form of injustice. 

What misconception do you find is common regarding these cuts?

Tavares: If you tell the average person that there may be a work requirement on Medicaid—and if you don’t understand who that impacts and what that means—it may sound good. You may think, if someone gets a government benefit, then they should work, right? But when people understand exactly what a work requirement is—how it functions, who it impacts, what happens when you put it in place—then no one wants it anymore. They realize what it would mean to implement this and how it impacts far more people than those the policy is aimed at.

Your pieces have shown that immediate cuts to Medicaid may incur greater longer-term costs. How can Medicaid cuts result in higher expenses down the road?

Cohen: The beautiful thing about giving people insurance is that they can access care and they’re more likely to engage in the healthcare system when they have an ability to influence health outcomes. With insurance, people engage in more preventive care, and they use the appropriate services at the time they’re needed. When you cut that link, people wait and they don’t go to their primary care physician, which is a low-cost service. Instead, they wait until they get really sick, creating higher rates of emergency room use and inpatient hospitalizations. Healthcare costs get much higher.

Moreover, these costs get passed on to other sectors in the healthcare system.  For example, hospitals are required by law to provide care to people who show up at their doorstep. When a certain percentage of patients are uninsured and can’t pay, then everyone who has insurance will end up being charged a higher rate to make up for that. With these cuts, you’ll see a large number of hospitals closing, in particular in rural areas that have higher percentage of people on Medicaid, because these cuts will put them in a loss position.

What is the purpose of a health care system? It’s to produce good health. When you make it harder for people to pay, when you make it harder for people to find services, the health care system produces poorer health outcomes. So one must ask: what will these cuts accomplish at the end of the day?

What are some potential impacts that can’t be quantified by dollar figures?

Tavares: Imagine being on Medicaid right now and watching all this happen. Think about the anxiety and the stress. Many beneficiaries are already thinking about, “What am I going to do if I can’t get my basic health care needs met?” “What happens if I don’t have coverage for my autistic adult child?” “What happens if no one pays for the care that my mom is receiving at home anymore? How am I going to deal with that? There’s a toll already being taken on some of the most vulnerable Americans before the cuts are even made, and it only stands to get worse.”

Cohen: With these cuts, you will end up having a sicker population. You’ll have declines in health and increases in mortality rates. Most of these proposed cuts will hit working people, so you could see, potentially, a loss of productivity in the economy.

Even if someone believes that there’s waste, fraud, or abuse in the healthcare system, they can’t possibly believe that cutting health insurance to the most vulnerable American will produce better health outcomes.  It is using a sledgehammer on a countertop to kill an ant. 

What records and data do you base your research upon?

Cohen: We’re using national data that is published by the U.S. Census Bureau, and that is the Health and Retirement Study, which includes data that’s been collected for more than 20 years on retirement status, health status, and the use of government benefits. It’s considered the gold standard for aging research and it allows us to model out the impacts of various changes to health policy on many different population segments.

Tavares: As researchers, we have replication in mind, so we are really good about saying, here’s my data source, this is how I measured it, and this is what was accounted for. We’re trained from day one to put enough detail into our research so that someone else can do it, too. That hasn’t always been the case in the political world or in the media. You hear estimates and narratives without anyone really understanding what was factored into those estimates or whether those narratives were based on empirical facts.

Is there a part of the conversation about Medicaid cuts that you believe warrants more attention? What’s being missed in the predominant dialogue?

Tavares: When home and community-based services get cut, oftentimes, other family members pick up the slack. It’s the kids, it’s the spouse, it’s family and friends who pick up the duties to care for that person. That creates a new stress and a burden—in a financial, physical, and mental health sense—on those caregivers who make up for the lack of services. That person might be forced out of the workforce or into a part-time role. Their health may deteriorate. Then, when those caregivers get older and eventually go on Medicare, they’re in worse financial and physical health. What’s missing from the discourse is that this isn’t about cost savings but shifting costs elsewhere and making them worse in the long-term.

Cohen: When you break the link of insurance, you break the link between a person and a trusted source of care, which is critical to produce better health outcomes. When the link is broken, a person will be less likely to go to medical appointments, will be less likely to fill prescriptions, and will be less likely to follow through on recommended treatments. We did an analysis, and the data show that without this link to a trusted source of care, health deteriorates. People are three times more likely to get basic, preventive services if they have insurance and a usual source of care.

Medicaid is a lifeline for people. People die when they don’t have it. Yet the conversation is becoming fixated on dollars and cents, rather than on the human beings that the healthcare system is designed to serve.  It is heartbreaking. 

How will LeadingAge LTSS work moving forward, if the bill passes?

Tavares: We’ve talked with advocates this week to tell them that we’re still with them, and that it’s time to think ahead. Let’s assume in the next few months that these cuts become a reality. What are their priorities? What research will they need to begin implementing systems to mitigate the damage? Maybe it’s figuring out how to change the resources we have in place to serve people in a different way or affect the patient experience so that we can encourage the use of preventative care, even with limited insurance, so that we see less crisis-driven emergency care. There’s a lot of work that will need to be done and hearing directly from the advocates on where we can be the most effective is key. We’re not here to be partisan. We’re here to provide non-partisan facts that organizations need to plan and continue forward.

Read More

Read some of the recent pieces written by Marc Cohen and Jane Tavares, both with the LeadingAge LTSS Center @UMass Boston:

When You Lose your Health Insurance, You May Also Lose Your Primary Doctor – and That Hurts Your Health (The Conversation)

History Repeats? Faced With Medicaid Cuts, States Reduced Support For Older Adults and Disabled People. (Health Affairs Forefront)

Who is Affected by Medicaid Work Requirements? It’s Not Who You Think (The Milbank Quarterly)

Why Do Cuts to Medicaid Matter for Americans Over 65? 2 Experts on Aging Explain Why Lives are at Stake. (The Conversation)

The Fundamental Flaw in “How Workers Spend Their Time” (Geiger Gibson Program at George Washington University)

Infographic: Who are “Able-Bodied” Non-Working Medicaid Beneficiaries?