Problem Statement: In the absence of Universal Health Care Coverage in the United States, Medicare and Medicaid play a critical role in providing access to medical services for elderly, disabled and low-income patients (1). Financial and budget considerations urge policymakers to limit these services further restricting Medicare eligibility age (2,3) or tightening requirements for Medicaid coverage. According to a study by Wilper et al., in the United States inadequate health coverage will increase the risk of mortality by 40% as limiting access to primary care and delay treatment (4). In the study by Pandey et al, increasing the Medicare coverage age from 65 to 67 would result in an estimated extra 17,244 death between 2023 & 2028(1).

The current political atmosphere concerns public health experts and medical community. It demands reevaluation of Medicare and Medicaid role in public health, prediction and implications of policy changes on health loss, especially mortality and morbidity (1). Mortality and morbidity for various conditions vary significantly in the U.S. based on the state and funding coverage for federal health programs. This variation provides an opportunity to investigate current coverage of Medicare and Medicaid across different states in elderly and evaluate the trend of mortality based on level of access, coverage and cost amongcurrent CMS beneficiaries. In this project we evaluated how access to and funding of CMSprograms affected mortality among the most fragile adult U.S. population – senior citizens.

Hypothesis: State -level variations in elderly total mortality and cancer mortality rates in elderly (age > 65 years old) are associated with Medicaid/ Medicare coverage, utilization and spending.

Methods and Material: Description of dataset: Data for total and specific cause mortality and coverage/ cost of Medicare/ Medicaid for 2021 was obtained from following sources: 1- The Kaiser Family Foundation (KFF) provides data for programs covered by Centersfor Medicare & Medicaid Services (CMS). We have 2 datasets as follows: a. Medicare enrollment, payments, and utilization, b. Medicaid spending and enrollment

2- CDC wonder is publicly available through CDC’s National Center for Health Statistics (NCHS). We have 2 datasets from this source: a. cdc_wonder_population: Age stratified population across states b. cdc_wonder_mortality: crude mortality rates across states stratified by age and ICD 10 cause of death.

Analytical software and Methods. We used R studio software and related packages. We imported population, mortality, Medicare and Medicaid datasets and applied different data cleaning techniques: 1. summarizing and filtering seniors > 65 years as one group, 2. selecting total mortality and cancer mortality as outcome of interest, 3. decoding variable state and using residence state as key variable across 4. tables, 5. handling missing data, 6. converting payment and spending to numerical data type, 7. renaming variables in “snake” format.

Finally, we joined different tables and calculated total mortality rate, cancer mortality rate, Medicare and Medicaid coverage rate as well as spending rate per member.

We then graphed mortality and coverage across states Lastly, we performed a trend visualization for total mortality and cancer mortality vs Medicare/Medicaid coverage and spending across the U.S.

We define data types for all varaibles to align with other tables

Results:

Table 1 highlights mortality rates per 100K among seniors (total, malignancy/ benign neoplasm) across states which are >10% above US average. Three states (Mississipi, Ohlahoma, West Virginia) have total mortality rates > 20% and seven states (Alabama, Arkansas,Indiana, Kentucky, Louisiana, Ohio, Tennessee) have rates 10% to 20% above U.S. average.

Figure 1 shows that variability in malignant-related mortality rate across states is less than variability in total mortality.

#Green is equal or below U.S. average; white is up to 10% above U.S. average; #yellow is 10% to 20% above U.S. average; red is more than 20% above U.S. # average

Table 2 highlights Medicare and Medicaid Coverage and spending among seniors which are 10%- 20% or >20% less than above US average. Notably, Medicare coverage is more uniform across stastes compared to Medicaid

Figure 2 shows Medicaid has a limited coverage compared to Medicare across US Figure 3 shows that spending/enrolled has a high variability across states and Medicare/Medicaid.

# Green color highlights rate equals or more than U.S. average White color highlights rate up to 10% less than U.S. average Yellow color highlights rate 10% to 20 % less than U.S. average Red color highlights rate lower than 20% below U.S. average

Finally, our trend analysis (Figure 4-5) shows that total mortality decreases with expanding health coverage. Medicare enrollment has a stronger effect. However, increased spending per enrollee has a tendency to be associated with higher mortality in Medicare beneficiary as opposed to Medicaid beneficiary.

Slightly different trends observed with cancer-related mortality. Cancer mortality is correlated with Medicare Spending /enrolled while it does not show notable trend with Medicaid enrollment/ spending.

Discussion:

We demonstrated that enrollment and spending rate in CMS programs can differ substantially in various states. This however does not necessarily lead to improved cancer-related or total mortality. It seems various confounding factors (geographic, financial, political, cultural, economic) can significantly affect or contribute to mortality rates.

Medicare coverage has a more visible trend effect. On the other hand Medicaid spending has a more favorable effect on mortality. The latter likely represent more socially disadvantageous economic group for which health coverage is essential for a better outcome.

As for cancer-related mortality, interpretation must account for the fact that cancer by its nature can be very aggressive disease and remains one of the leading causes of death overall. Increased spending per Medicare enrolled may reflect high overall morbidity and subsequent higher mortality from cancer.

Finally, “outlier” states with significant less spending or enrollment than the U.S. average don’t have a clear direction in analysed associations.

Conclusion: In summary, states with better Medicare and Medicaid enrollment and spending per enrolled have better overall mortality rates however this is not reflected in cancer-related mortality.

reference:

1- Pandey A, Fitzpatrick MC, Singer BH, Galvani AP. Mortality and morbidity ramifications of proposed retractions in healthcare coverage for the United States. Proc Natl Acad Sci U S A. 2024 Apr 30;121(18) 2- 1.Van de Water P. N., Raising Medicare’s eligibility age would increase overall health spending and shift costs to seniors, states, and employers. Center on Budget and Policy Priorities (2011) (16 January 2024). 3- 2.Waidmann T. A., Potential effects of raising Medicare’s eligibility age. Health Aff. 17, 156–164 (1998).  4- Wilper A. P., et al. , Health insurance and mortality in US adults. Am. J. Public Health 99, 2289–2295 (2009)