In States Considering Medicaid Expansion: Ignore the Myths and Look to the Evidence

Heidi Allen studies the impact of health and social policies on the well-being of low-income families. She was a leading investigator on the landmark Oregon Health Insurance Experiment—the first randomized study in the United States to evaluate the impacts of a Medicaid health insurance expansion on uninsured adults. Currently, Heidi is an Associate Professor in the School of Social Work at Columbia University, where she teaches courses on health policy and advanced policy practice. Heidi spoke at TEDMED 2017, and you can watch her Talk here.


In my TEDMED talk, I shared my personal experience of a family member who was diagnosed with stage IV cancer while uninsured. By the time my sister was diagnosed, the cancer was no longer treatable. I’m a professor at Columbia University who has studied U.S. health policy for the past decade, and even I had no idea how to help Rachel navigate the end of her life without health insurance. She died in a matter of weeks, which left us all stunned and devastated, but also spared her family the financial difficulties and subsequent access barriers that we inevitably would have encountered had she been given treatment options or required hospice.

Heidi and her sister, Rachel

I didn’t share my story because it was unique; I shared it because there are still millions of Americans who love someone who is uninsured or are themselves uninsured. In 2014, the Affordable Care Act (ACA) offered states the opportunity, and significant federal funding, to expand Medicaid to their uninsured poor. Yet many states have chosen not to do that, including Idaho, where my sister lived. The politics around the ACA – or “Obamacare”, as it is often called – are undeniable and complicated, but much of the policy debate still centers on the worthiness of either Medicaid or the uninsured poor. Whether society is obligated to care for the health needs of the uninsured is for many a moral consideration, but research can and should be used to help evaluate the costs and benefits of expanding Medicaid. Some of this research runs contrary to prevalent Medicaid myths that have been shaping the debate.

At TEDMED, I discussed these myths in the context of research findings from one of the most rigorous studies of Medicaid to date, the Oregon Health Insurance Experiment. The unique experimental design of the study allowed us to examine the impacts of Medicaid while ruling out confounding factors burdening many other Medicaid studies. Put simply, we were able to make causal statements about Medicaid outcomes rather than describing associations or having to compare groups that aren’t easily comparable.

One of the most insidious myths out there is that Medicaid does not provide much benefit beyond what is already accessible to the poor through the social safety net. George W. Bush once asserted that everybody in the U.S. has access to health care because emergency departments are required to provide it. There are elements of truth to this argument – indeed, it was in the emergency department where my sister learned she had tumors in her lungs. But emergency departments are there to assess and stabilize patients, not to provide the continuum of needed health care services. To access these health care services, you need health insurance, or a good amount of disposable wealth. The Oregon Experiment found that compared to the uninsured, those who gained Medicaid through a health insurance lottery had improved access to all types of health care (inpatient, outpatient, and prescriptions); rated care they received of higher quality; had better self-reported physical and mental health; and saw improvement in their family finances.

A recent systematic review of the post-ACA research literature reinforces these conclusions about the Medicaid program, particularly related to how Medicaid improves access to care.

Other recent studies have found that Medicaid expansion increases access to benefits for substance-use disorder treatments, which is vital to addressing the current opioid epidemic. And another study found that Medicaid expansion reduced the use of payday loans in California, further supporting the case that Medicaid provides meaningful financial security, not just health security. In sum, the evidence is abundant and trustworthy that for low-income people, having Medicaid provides tangible benefits well beyond those available through the health care safety net.

This November, through ballot initiatives, voters in Idaho and Utah will get to decide the issue of Medicaid expansion for themselves. I hope my TEDMED Talk will contribute to a more meaningful discussion of what Medicaid expansion would mean.