We examine the causal effect of health insurance on mortality using the universe of low-income adults, a dataset of 37 million individuals identified by linking the 2010 Census to administrative tax data. Our methodology leverages state-level variation in the timing and adoption of Medicaid expansions under the Affordable Care Act (ACA) and earlier waivers and adheres to a preregistered analysis plan, a rarely used approach in observational studies in economics. We find that expansions increased Medicaid enrollment by 12 percentage points and reduced the mortality of the low-income adult population by 2.5 percent, suggesting a 21 percent reduction in the mortality hazard of new enrollees. Mortality reductions accrued not only to older age cohorts, but also to younger adults, who accounted for nearly half of life-years saved due to their longer remaining lifespans and large share of the low-income adult population. These expansions appear to be cost-effective, with direct budgetary costs of $5.4 million per life saved and $179,000 per life-year saved falling well below valuations commonly found in the literature. Our findings suggest that lack of health insurance explains about five to twenty percent of the mortality disparity between high- and low-income Americans. We contribute to a growing body of evidence that health insurance improves health and demonstrate that Medicaid’s life-saving effects extend across a broader swath of the low-income population than previously understood.
Saved by Medicaid: New Evidence on Health Insurance and Mortality from the Universe of Low-Income Adults
The Hidden Struggle of John Fetterman
Former and current staffers paint a picture of an erratic senator who has become almost impossible to work for and whose mental-health situation is more serious and complicated than previously reported. No one is saying every controversial position (for example, his respectful relationship with Trump) stems from his mental health — but it’s become harder for them to tell which ones do. When I spoke with Fetterman in April and shared those concerns, he denied anything was amiss. He told me that he felt like the “best version” of himself and later texted that the staff turnover at his office was typical of Washington. “Why is this a story?” he asked.
Those first days in the hospital were rough. Fetterman was experiencing delusions. He thought that if he took a bed at the hospital, he would be arrested. He told doctors that he believed members of his family were wearing wires to secretly record him. In one chaotic moment, Fetterman grew convinced that a political rally was being held in the hospital’s lobby and that he needed to break out of his room to attend. David Williamson, Fetterman’s doctor, told me that the main causes of the delusions were the lingering effects of the stroke, dehydration, and depression and that the original medication for the depression could also have been a factor. According to paperwork from Walter Reed, doctors then stopped all antidepressants and put him on other drugs. (Williamson declined to comment on the specifics of the medication plan.)
After six weeks in the hospital, the doctors determined his mental-health issues were in remission. Williamson said, “He expressed a firm commitment to treatment over the long term.”
Doctors provided Fetterman with a multi-faceted treatment approach. He needed to stay on his medication and to get his blood checked regularly. It was also important that he stay hydrated, so staff made sure his office fridge remained stocked with Gatorade. He needed to eat healthy and get regular exercise (this was both for his mental health and for the underlying heart problems that had led to his stroke). It was also strongly suggested that he stay off social media, which exacerbated his mental-health challenges. “I’ve never noticed anyone to believe that their mental health has been supported by spending any kind of time on social media,” he said in 2023.
it wasn’t until October 7 that it became clear Fetterman was the most outspoken Israel hawk in his party, offering constant and unconditional support for the military action in Gaza. Early on in the conflict, 16 of his former campaign staffers wrote a letter — anonymously — saying they found his full-throated support for Israel to be a “gutting betrayal.” Jentleson had taken to defending Fetterman on X from such criticisms, posting, “The thing about being a staffer is that no one elected you to represent them.”
In early November, just weeks after the attack, Gisele arrived at her husband’s Senate office and, according to a staffer present, they got into a heated argument.
“They are bombing refugee camps. How can you support this?” the staffer recalled her saying with tears in her eyes.
“That’s all propaganda,” Fetterman replied.
Later, a still visibly upset Gisele pulled the staffer aside. She asked him if members of Fetterman’s team were pushing him to take these stances for political reasons. The staffer told her that the opposite was true: Many of them were as upset as she was. “If you’re pushing back on this, there’s no hope,” the staffer recalled her saying. “This is horrible news.”
Gisele might have disliked what her husband was up to, but his father loved it. Karl Fetterman, an insurance executive, was way more conservative than his son. He used to have a magnet on his refrigerator that warned that his dog bites Democrats, and he watched Fox News constantly. When Fox would air segments about Fetterman’s strong stances on Israel or invite him on as a guest, the senator’s father would, according to former staff, almost always call to say how proud he was.
Gisele then texted that she had told her husband that his staff and doctor were worried about him but that he told her “that’s not true and I guess I am not talking to you today” before hanging up. The doctor had also “said that he was fighting to get access of the Twitter account,” she went on. “Please promise me that he’ll never have access.”
The staffer said that Fetterman was asking for the passwords but that he would not give them up.
“I told him I don’t want to talk to him until his blood is tested,” Gisele wrote.
There was also the possibility that Fetterman’s illness had drawn out or intensified his existing predilections. In some ways, Fetterman was being the guy voters sent to Congress. He keeps to himself? He cancels fundraising events last minute? He thinks a lot of his colleagues are morons? Make him president already! He was never a particularly easy person to work with — he’d had that reputation throughout his entire political career. So sometimes the staff would debate whether a fundamental change had occurred or they were just imagining things, particularly since there were stretches of time when he was lucid and together. “It got hard to know which way was up,” Jentleson told me. “Was he acting crazy, or were we overreacting? I asked myself that a lot.”
Years after the stroke, Fetterman continues to struggle with auditory processing. To chat with me, he had put an iPhone on the table that transcribed my questions to him in real time. Sometimes Fetterman wouldn’t finish reading a question before answering, and other times his sentences could come out a bit garbled. After a podcast taping earlier this year with The Bulwark, the interviewer Tim Miller came away feeling like Fetterman might not be all there. “He’s struggling,” Miller said in a separate podcast taping. “He’s, like, really struggling. And I just think coming off of the Biden thing, we should not be hiding the ball on this sort of stuff.”
But in my conversation with Fetterman, I didn’t find any indication that the stroke had left him cognitively impaired. Our interview lasted just over an hour, during the first half of which he seemed excited to discuss just about anything I threw at him. He had problems with the way Democrats had estranged themselves from the public, he said, but still had no intention of leaving the party to become a Republican or even an independent: “Same chance I’m going to end up with a beautiful head of hair.”
He said that no one in his staff would know about his personal health situation and that anyone who told me otherwise was simply misinformed. “There’s not really anything to respond when that’s just not accurate,” he said.
“What they say,” I pressed on, “is that they’ve witnessed ups and downs that could be associated with kind of a relapse. And they also worry that the medication that you’re on is not just for depression, but more serious drugs that if you’re not on them would be a problem. Is there truth to that?”
“I don’t have any comment on that,” he said. “I’m going to go off record. Go off record. Go off record.”
I cannot report what Fetterman said over the course of the next four minutes, but I can say that after he was done talking, I found myself in the hallway outside his office making awkward small talk with one of his press aides. Five minutes later, the door opened and I was ushered back in. The office felt different now. Quiet and tense. Fetterman was still in the same chair but slumped into himself, like a deflated parade float. His shoes were now on, and he avoided looking at me. Finally, I broke the silence. “Anything to say about that?” I asked, hoping to pick up our conversation where we had left off.
Why Do Employers Provide Health Care in the First Place?
In 2017, Americans spent $3.5 trillion on health care — a level nearly equal to the economic output of Germany, and twice as much as other wealthy countries spend per person, on average. Not only is this a problem for the people seeking care; it’s also a problem for the companies they work for. Currently, about half of Americans are insured through an employer, and in recent years companies have borne the financial brunt of rising costs. Frustrated, many employers have shifted the burden to workers, with average annual deductibles rising by more than 50% since 2013.
Opinion | Why the New Obesity Guidelines for Kids Terrify Me
In dozens of interviews with families I heard about doctors shaming low-income moms for buying dollar store ramen noodles instead of pricier fresh vegetables. I talked to teenagers who were gaining weight while dealing with depression or anxiety and whose doctors told them to cut carbs. Families described doctors who rushed conversations, grabbed bellies or made jokes about kids’ bodies.
What should the obesity guidelines say instead? Stop classifying kids and their health by body size altogether. This would involve a paradigm shift to weight-inclusive approaches, which see weight change as a possible symptom of, or a contributing factor toward, a larger health concern or struggle. These approaches focus providers on addressing that issue rather than managing weight loss. This means looking less at the number on the scale and talking more to families about their health priorities and challenges. Can they add healthy foods rather than restrict calories?
We cannot solve anti-fat bias by making fat kids thin. Our current approach only teaches them that trusted adults believe the bullies are right — that a fat body is just a problem to solve. That’s not where the conversation about anyone’s health should begin.
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