What are the best and worst places to stay healthy as you age? For answers, take out a map and follow the Mississippi River from north to south. The healthiest people over 65 are in Minnesota, the sickest in Mississippi.
That's among the findings of the America's Health Rankings Senior Report released in May by the United Health Foundation. The report ranks the 50 states by assessing data covering individual behavior, the environment and communities where seniors live, local health policy and clinical care.
Minnesota took top honors for the second year in a row, ranking high for everything from the rate of annual dental visits, volunteerism, high percentage of quality nursing-home beds and low percentage of food insecurity. This year's runners-up are Hawaii, New Hampshire, Vermont and Massachusetts. (See how your state fared here.).
The researchers base their rankings on 34 measures of health. But here's one you won't find in the report: state compliance with the Affordable Care Act (ACA). While the health reform law isn’t mainly about seniors, it has one important feature that can boost the health of lower-income older people: the expansion of Medicaid.
The ACA aims to expand health insurance coverage for low-income Americans through broadened Medicaid eligibility, with the federal government picking up 100% of the tab for the first three years (2014-2016) and no less than 90% after that. But when the U.S. Supreme Court affirmed the ACA’s legality in 2012, it made the Medicaid expansion optional, and 21 states have rejected the expansion for ideological or fiscal reasons.
And guess what: Most of the states with the worst senior health report cards also rejected the Medicaid expansion.
Nearly all Americans over age 65 are covered by Medicare. But the Medicaid expansion also is a key lever for improving senior health because it extends coverage to older people who haven’t yet become eligible for Medicare. That means otherwise uninsured low-income seniors are able to get medical care in the years leading up to age 65—and they are healthier when they arrive at Medicare’s doorstep.
Two studies from non-partisan reports verify this. The U.S. Government Accountability Office reported late last year that seniors who had continuous health insurance coverage in the six years before enrolling in Medicare used fewer and less costly medical services during their first six years in the program; in their first year of Medicare enrollment, they had 35% lower average total spending.
The GAO study confirmed the findings of a 2009 study report by two researchers at the Harvard Medical School. That study looked at individuals who were continuously or intermittently uninsured between age 51 and 64; these patients cost Medicare an additional $1,000 per person due mainly to complications from cardiovascular disease, diabetes and delayed surgeries for arthritis.
Fifty-two percent of Medicaid-rejecting states ranked in the study’s bottom third for senior health, including two very large states, Texas and Florida. Many of these states also can be found in a list of states with the highest rates of poverty among people over 65.
What emerges is a north-south divide on senior health. “Many states that haven't expanded Medicaid are in the South, and there’s a clear link between socioeconomic status and health status,” says Tricia Neuman, senior vice-president at the Henry J Kaiser Family Foundation and director of the foundation's Medicare policy program. "Insurance may not be the only answer, but it certainly is helpful."
The United Health Foundation—a non-profit funded by the insurer UnitedHealth Group— didn't consider insurance coverage in its study, but it did consider poverty. Minnesota's rate was 5.4%—well below the 9.3% national rate. Mississippi ranked dead last, with a 13.5% poverty rate.
In states that rejected the Medicaid expansion, we are witnessing a victory of politics over compassion and morality. Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology and a key architect of health reform in Massachusetts and under the ACA, summed it up in an interview with HealthInsurance.org earlier this year, saying that these states "are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness."