Child Mortality, Inequality, and the ACA Medicaid Expansion

October 9th, 2014 at 8:33 am

Starting back to the 1980s, I and others wrote about the growing trends in income, wages, and wealth inequality with some alarm. That early work was important, but it was also missing something important: the impact of rising inequality.

There’s now a growing body of research documenting this impact on various dimensions of opportunity and even macroeconomic growth. Add to that this new study, already reported on in various venues, which finds that income disparities in the US are a significant factor in our high infant mortality rate, a rate that makes us a big outlier among advanced economies (see WaPo link above for that figure).

The authors, Alice Chen, Emily Oster, and Heidi Williams, write:

This postneonatal mortality disadvantage [deaths in months 1-12] is driven almost exclusively by excess inequality in the US: infants born to white, college-educated, married US mothers have similar mortality to advantaged women in Europe. Our results suggest that high mortality in less advantaged groups in the postneonatal period is an important contributor to the US infant mortality disadvantage.

It’s a careful study allowing for the type of “all else equal” comparisons that are essential is teasing out international differences. The authors find that most of the U.S. shortfall comes not from the neonatal period (first month after birth), but the postneonatal period.

Using comparable data from Finland and Austria, they show that mortality rates in the postneonatal period are essentially indistinguishable between different economic groups and education levels.  And the U.S. mortality rates for infants born to white, educated, married mothers is essentially indistinguishable from the mortality rates for infants in those two other counties. Again, the outlier is less-advantaged groups in the U.S., who have significantly higher mortality rates.

The authors suggest that having nurses make home visits in the first year after birth, much more common in Europe, could help narrow the differences they document. Since such home visits are also associated with health coverage, this led us (CBPP’s Brandon DeBot and I) to think about the Medicaid expansion under the Affordable Care Act. While it’s true that many poor children are already covered under the child version of Medicaid—CHIP—their parents are often uncovered and disconnected from health systems that could help them in these circumstances.

There’s also great variation among states. According to the WaPo, “If Alabama were a country, its rate of 8.7 infant deaths per 1,000 would place it slightly behind Lebanon in the world rankings. Mississippi, with its 9.6 deaths, would be somewhere between Botswana and Bahrain.”

Putting these facts together leads to a discomforting finding: child mortality rates are significantly higher in states that have thus far declined to accept the Medicaid expansion part of Obamacare. While the overall average infant mortality rate in 2010 was 6.15 deaths per 1,000 births, the average for states expanding Medicaid was 5.72 deaths per 1,000 births, compared to 6.70 deaths per 1,000 births in the non-expansion states.

Correlation not being causation, it’s not that child mortality is higher because fewer parents have access to health coverage in these states. They’re also poorer. But it does not feel like a reach to argue that expanding affordable health coverage to places where far too many children perish in their first year of life would be a positive change. To not do so based on ideological opposition to the expansion of a government programs is unconscionable.

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One comment in reply to "Child Mortality, Inequality, and the ACA Medicaid Expansion"

  1. Robert Salzberg says:

    We do know that lack of medical insurance increases morbidity and mortality. A Daily Kos post earlier this year details how lack of Medicaid expansion is literally killing people.

    With all the phony outrage on the Right over things like President Obama saluting with a cup of coffee, is it time for progressives to forcefully confront politicians that punish their fellow citizens by refusing to expand Medicaid?