Better Access to Public Insurance Reduced Infant Mortality During an Influenza Pandemic

Does improved access to public health insurance save lives during a pandemic? A new study assessed how better access to public health insurance affected infant mortality related to two flu pandemics in the last century, one before and one after the introduction of Medicaid. The study found that better access to insurance in high-eligibility states substantially reduced infant mortality during the pandemic that occurred after Medicaid was introduced. The findings have implications for policymaking during current and future pandemics.

The study, by researchers at Carnegie Mellon University (CMU) and the University of Montreal, is published as a working paper of the National Bureau of Economic Research.

“We estimate that better access to public health insurance in high-eligibility states led to a six to seven percent decrease in infant mortality during the 1968-69 pandemic, averting approximately 2,700 infant deaths,” explains Karen Clay, professor of economics and public policy at CMU’s Heinz College, who led the study. “By demonstrating the value of improved health care access to reduce the severity of a pandemic, our findings have relevance for the mitigation of the current coronavirus and for future outbreaks.”

Researchers looked at the effects of cross-state variation in mandated eligibility for Medicaid on infant mortality during two influenza pandemics: the Asian flu in 1957-58 and the Hong Kong flu in 1968-69. Each pandemic was responsible for 50,000 to 100,000 excess deaths in the United States. Medicaid, the federal and state program that helps with medical expenses for low-income families, was established in 1965.

The study used annual county-level data on infant mortality for 1950-1979. It measured state eligibility for insurance under Medicaid in all U.S. cities by using data on the share of women who received benefits under the Aid to Families with Dependent Children (AFDC) program in 1965, given the close link between welfare participation and enrollment in Medicaid.

The severity of the two pandemics varied considerably across the United States, in part due to underlying air pollution and urbanization. To measure differences in severity, the study focused on local air pollution (measured by the total capacity of coal-fired power plants) and urbanization (measured by counties’ share of urban population).

The study found no relationship between eligibility for AFDC (which the study used as a proxy for Medicaid since Medicaid did not exist in 1957-58) and infant mortality during the first outbreak. After Medicaid was implemented, the study found that better access to insurance in high-eligibility states substantially reduced infant mortality during the second pandemic. The study’s authors conclude that expansions in insurance eligibility may have resulted in improved access to physician services and hospital care.

The authors note that reductions in infant mortality during the second pandemic were too large to attribute solely to the new Medicaid recipients, suggesting that the expansion in health insurance coverage mitigated the spread of the disease to the broader population.

“Our results suggest that improved access to medical care through expansions in public insurance may play an important role in reducing mortality during health crises like pandemics,” says Edson Severnini, assistant professor of economics and public policy at CMU’s Heinz College, who coauthored the study. “However, because these episodes arrive infrequently, the benefits may not be captured by policy evaluations focused on the immediate aftermath of implementation.”

The research was funded by the Center for Electricity Industry Studies, Heinz College, the Berkman Fund at Carnegie Mellon University, the National Science Foundation, and the University of Montreal. 

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Summarized from an NBER working paper, The Value of Health Insurance During a Crisis: Effects of Medicaid Implementation on Pandemic Influenza Mortality  by Clay, K (Carnegie Mellon University), Lewis, J (University of Montreal), Severnini (Carnegie Mellon University), and Wang, X (Carnegie Mellon University). Copyright 2020. All rights reserved. 

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