Large-scale Medicaid disenrollment in Tennessee nearly 20 years ago led to increased total crime rates, a new study by the National Bureau of Economic Research found.
Specifically, the working paper shows that nonviolent crime increased following disenrollment, and there is "suggestive evidence" of an increase in violent crime.
"We find that the median county experienced a 16.6% increase in crime rates, with violent and non-violent crime rates raising by 20.6% and 14.1% respectively," said health economists and professors Monica Deza, Thanh Lu, Alberto Ortega and Catherine Maclean, the authors of the study.
They noted assault and theft as the most common drivers of violent and nonviolent offenses. Mental health and substance use disorder outcome changes appeared to be the primary effects of the disenrollments, as not receiving substance use disorder treatment and deaths increased.
In July 2005, the Centers for Medicare & Medicaid Services approved Tennessee's request to terminate TennCare, a Section 1115 waiver to the state's Medicaid program first approved in 1993. The program provided insurance to a broader population successfully—maybe too well. One in 4 adults were enrolled in TennCare, and the program accounted for 30% of the state's budget.
"In the second two quarters of 2005, 10% of the Medicaid population and 3% of the state population, or 190,000 people, lost Medicaid," explained the authors. "Disenrollees were predominantly childless, non−disabled, non−elderly beneficiaries with income levels in the range of 100% and 175% of the federal poverty level."
Analysis determines that TennCare disenrollment led to 270 crimes in the median county, and that 11.46 additional crimes per 1,000 residents for a police agency in a median county occurred. It's reasonable to assume suddenly losing insurance coverage could be closely linked to crime if deteriorated mental health and substance use outcomes are the consequence, the authors speculate.
To explore the issue, the authors compared violent and nonviolent crimes from 2002 to 2007 from the FBI's Uniform Crime Reports database.
Other studies have evaluated the relationship between health insurance and crime. For example, Medicaid expansion has been shown to reduce police arrests, according to one study found in the National Library of Medicine.
The Tennessee crisis also was found to affect housing, an important social determinant of health. Disenrollment led to a 27.6% increase in the annual number of eviction filings from 2005 to 2009, a recent study in Health Affairs showed.
As the COVID-19 pandemic public health emergency has ended, states have begun to unwind continuous coverage provisions, causing more than 18 million Americans to lose Medicaid insurance, KFF has reported. Other states have dragged their heels, to varying degrees, on the issue of Medicaid expansion, and some states have tied work requirements to Medicaid eligibility.
However, the Affordable Care Act provides subsidies for private coverage for family incomes up to 400% of the federal poverty level, meaning they potentially have more coverage options than their 2005 TennCare counterparts.
Today, more than 88 million Americans are on Medicaid, while more than 20 million Americans are uninsured.
The National Institute on Mental Health supported this study.