Digest 65: Medicaid and mortality.

May 30, 2025 | By Nora Taranto

Welcome Back to The Curbsiders Digest!

In this issue, we discuss Medicaid and mortality, plus combination therapy versus statins alone, a new med for smoking cessation, anti-virals for the flu, at-home screening for cervical cancer, and more! Effortlessly absorb important medical news, with our twice monthly newsletter featuring easily digestible analysis of the latest practice-changing articles, and of course…bad puns. 

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Issue 65

05/30/2025

Appetizers (to whet your appetite) 

Palate Cleanser (aka the melon part of the meal) 

The Main Course

A Digestif or two

Appetizers

Brought to you hot off the stove, from a variety of specialties. Delivered in super tasty, bite-sized morsels. 
-Beth Garbitelli MD, Joshua Gilman MD, Laura Glick MD, and Alyssa Mancini MD

• Combination lipid-lowering therapy – better than a statin alone? A moderate-intensity statin + ezetimibe may lead to fewer statin-associated muscle symptoms (SAMS) and similar LDL target achievement compared to high-intensity monotherapy according to the SaveSAMS trial, just published in J. Intern. Med. This prospective, multicenter, open-label trial in South Korea randomized 561 statin-naïve adults > age 70 with atherosclerotic cardiovascular disease (ASCVD) to rosuvastatin 5 mg + ezetimibe 10 mg (combination group) or rosuvastatin 20mg (high-intensity), with a primary outcome of positive SAMS (defined as a score of >7 on the statin myalgia clinical index, including myalgias, cramps, stiffness, and weakness) at 6 months. The combination group experienced a lower incidence of SAMS compared to the high-intensity group (0.7% vs. 5.7%; OR 0.12; 95% CI, 0.03-0.53; p=0.005). Secondary outcomes were notable for similar rates of LDL-target achievement and a lower rate of new-onset diabetes with combination therapy. (JG) 
• A new smoking cessation medication! The ORCA-3 phase III clinical trial was a double-blind, randomized, placebo-controlled trial evaluating the efficacy and tolerability of cytisinicline for smoking cessation. Just published in JAMA Intern Med, this study randomized 792 adults who smoked at least 10 cigarettes daily and sought to quit smoking to 12 weeks of cytisinicline, 6 weeks of cytisinicline followed by 6 weeks of placebo, or 12 weeks of placebo. All groups received behavioral support. The primary outcome was biochemically verified continuous smoking abstinence (verified by weekly carbon monoxide levels <10ppm) during the last 4 weeks of treatment. Cytisinicline led to smoking abstinence more frequently than placebo for both the 6- and 12-week cytisinicline groups (15% with cytisinicline versus 6% with placebo for the 6-week treatment group comparison, p<0.001, and 30% vs. 9% for the 12-week treatment comparison, p<0.001). Participants who received cytisinicline had reduced cravings and were also more likely to be abstinent at 24 weeks. The drug was well-tolerated with no serious adverse events in the treatment group. Following these results and a separate randomized trial from May 2023, cytisinicline is expected to be submitted for FDA approval in June 2025. (LG) 
• No Quick Fix for Flu. Further evidence might convince you to skip out on treating influenza with antivirals. In a new meta-analysis published in JAMA Internal Medicine, researchers evaluated 73 studies including almost 35,000 eligible participants and found that compared with placebo, all antivirals had little to no effect on mortality in patients, regardless of whether patients were at low or high risk of severe complications.  Most had limited impact on hospital admissions, with a possible signal that baloxavir might reduce hospitalization risk in higher risk patients.  Baloxavir (and maybe umifenovir) also seemed to reduce symptom duration, but the mean difference was only 1 day. Notably, oseltamivir did not seem to reduce hospital admissions or reduce symptom burden in patients, but it did seem to increase adverse events. (BG) 
• The next cancer screening frontier – at-home paps? Exciting cancer screening news–a wand-shaped tool (brand name: Teal Wand) just received FDA approval for self-collected, at-home cervical cancer screening. Cervical cancer is one of the most preventable cancers, thanks to both screening tests and the human papillomavirus (HPV) vaccine. But screening uptake has remained a challenge (especially since the pandemic). And per NCI, about half of US cervical cancer cases are diagnosed in patients who report never or infrequent screening. The Teal Wand device (price TBD) operates a bit like a tampon, with a retractable sponge tip that collects a sample for HPV testing–with a telehealth service to review use and test results.  Data reviewed by the FDA comes from the industry-funded Self-CERV study, which showed similar test performance of the Teal Wand’s self-collected samples to clinician-collected samples, and patient preference for self-collection at home. Other studies have also increasingly demonstrated the efficacy of at-home HPV collection kits (Arbyn 2022, Inturrisi 2021), and the ongoing SHIP trial will provide essential information about clinical validity and utility of self-collection compared to clinician-collection. (BG) 
• Once weekly semaglutide in MASH/ liver fibrosis. NEJM recently published the results of a planned interim analysis of ESSENCE, a phase 3, multicenter, randomized, placebo-controlled trial of 1197 patients with biopsy-proven metabolic dysfunction-associated steatohepatitis (MASH) and moderate or advanced liver fibrosis (stage 2 or 3). Patients were randomized (2:1) to receive once-weekly subcutaneous semaglutide 2.4mg or placebo for 240 weeks. This interim analysis assessed liver biopsy results at week 72 for the first 800 randomized patients. Resolution of steatohepatitis without worsening of fibrosis occurred more with semaglutide (62.9% with semaglutide vs 34.3% with placebo, estimated difference 28.7%, 95% CI 21.1 to 36.2, p<0.001). Reduction in liver fibrosis occurred in 36.8% of those receiving semaglutide (compared to 22.4% with placebo). Combined resolution of steatohepatitis and liver fibrosis reduction (a secondary outcome) occurred more with semaglutide (32.7% vs 16.1% with placebo). Greater change in body weight occurred with semaglutide (-10.5%  vs -2.0% with placebo), and gastrointestinal adverse events occurred more frequently with semaglutide. (AM) 

Palate Cleanser

The melon part. To get rid of the taste of those pesky apps.  And to fill your brain with some fun facts.

“One day from now will be a long time ago.”

If that hits close to home, you might enjoy a recent episode of The Happiness Lab with Dr. Laurie Santos, featuring Gretchen Rubin—author of the book, Secrets of Adulthood. Together, they explore the surprising power of aphorisms: concise, thought-provoking pearls of wisdom that somehow manage to be simple yet clever and profound. She’s packed over 200 of these into her new book—perfect for anyone navigating the chaos of modern adulthood with equal parts humor and existential dread. 

A few that struck me:

“It is by changing our words that we can change our perspective” 
“Sometimes to keep going, we need to allow ourselves to stop”
“Focus on actions, not outcomes”

Tune into the episode to hear more aphorisms that might change how you think about things (or at least help you survive Monday). 

– Jennifer DeSalvo MD 

The Main Course

Jennifer DeSalvo MD 

Medicaid in the Crosshairs
As Congress works to pass a federal budget before the new fiscal year in October, Medicaid is once again a focal point of debates. Funded by contributions from both states and the federal government, Medicaid provides health insurance to those with limited income, including families with children, older adults, and people with disabilities. But Medicaid is expensive, representing nearly 20% of healthcare spending. Proposed federal budget cuts may therefore significantly alter the program’s funding structure. Additionally, renewed calls for work requirements for beneficiaries and concerns over alleged fraud and waste aim to reshape eligibility. These proposed changes are highly contentious, with opponents warning that cuts will potentially lead to severe health consequences for millions of low-income individuals. 

So are those hoping to save Medicaid being fiscally irresponsible, or are we buying something worthwhile when we pay for health insurance through Medicaid? 

Quasi-experiments
Multiple studies have explored the impact of health insurance on mortality– and no matter the data used, or the study design, high-quality research shows health insurance coverage saves lives. Many of these studies have used quasi-experimental designs. A quasi-experimental study aims to establish a cause-and-effect relationship, but unlike a true experiment, it does not involve random assignment of participants to treatment and control groups. It instead relies on naturally occurring interventions (such as a policy going into effect).  You can infer such an intervention’s causal effect by comparing what happens to people exposed versus not exposed to it, as these naturally occurring interventions or policies happen at a population level, and exposure shouldn’t depend on individual patient characteristics–besides living in the area where the intervention is implemented. This methodology removes some of the challenges of studying health insurance, as one does not randomly assign individuals to get health insurance, and as those with health insurance are often very different from those without it. Researchers have therefore used this approach to study health insurance policy changes, assessing what happens to people exposed to the policy (i.e. those with more access to health insurance) versus those who are similar but happen not to be exposed to the policy (i.e. those with less access).

Consider a 2012 NEJM paper assessing Medicaid expansion using a quasi-experimental design. This study investigated how state Medicaid expansions affected mortality and access to care. Investigators calculated mortality rates and healthcare access measures in three states that significantly expanded Medicaid for adults (Arizona, Maine, and New York) between 2000-2005, compared to neighboring states without such expansions–assessing outcomes both before and after the reforms (1997-2007). Medicaid expansions were associated with a significant 6.1% reduction in all-cause mortality (19.6 fewer deaths per 100,000 adults). However, this study, which focused on population-level data and did not comment on Medicaid’s financial return-on-investment, was not without its limitations. 

Enter the Economists 
Because people are rarely randomized to the job they have or their salary, economists are quasi-experimental design experts. And in a hot-off-the-press 2025 National Bureau of Economic Research working paper, they tackle the issue of what exactly we get by paying for Medicaid. The authors collected individual-level data for 37 million low-income adults by linking 2010 Census data, 2009 IRS tax data, Centers for Medicare and Medicaid Services administrative datasets, and Social Security Administration data to determine this cohort’s demographics, family structures, income, enrollment in Medicaid, and deaths. After this herculean data cleaning task, they compared changes in outcomes (mortality and cost) in states that expanded Medicaid under the Affordable Care Act to those in non-expansion states, also leveraging state-level variation in when exactly Medicaid expansion occurred. Because of their immense data linkages, they were able to control for both individual characteristics, state characteristics, and the year being studied.

First, they demonstrated that when states expanded Medicaid eligibility, more people in those states did indeed get Medicaid insurance. They then reported that Medicaid expansion reduced the likelihood of mortality in low-income adults by 2.5 percent. They estimate that Medicaid expansion saved ~27,400 individual lives between 2010 and 2022, amounting to 3200 avoided deaths per year in post-expansion states. Notably, this reduction was seen across numerous subgroups and age groups; in fact, younger adults accounted for nearly half of the life-years saved (due in part to longer remaining lifespans). Moreover, expansions appeared to be cost-effective, with direct budgetary costs of $179,000 per year-of-life saved.

Medicaid saves lives
The evidence at this point seems compelling –that health insurance generally, and Medicaid specifically, saves lives. What’s more, the latest evidence suggests it does so in a cost-effective manner.  Whether and how to fund Medicaid remains a political question, but whether it accomplishes its goal of helping Americans live longer, healthier lives is an empirical one that seems to have been robustly and definitively answered.

Read The Study Here!

Digestifs

Before you go….
we’ve got a few nibbles!

Consolidate your learning with a Quiz!  

This week on The Curbsiders: In Episode #484, get an earful, with the latest hotcakes to arrive in your inbox, brought to you by a phenomenal Digest/hotcakes crew! To stay up on the literature, listen to this episode to learn the latest on vitamin D and omega-3 fatty acids, gabapentin and falls, the newest antibiotic for uncomplicated UTI, and intermittent fasting for weight loss. 

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The Curbsiders Digest

Issue 65

Editor in Chief: Nora Taranto MD

Banner: Kate Grant  MBChB, DipGUMed

Jennifer DeSalvo,  Beth Garbitelli, Josh Gilman, Laura Glick, Alyssa Mancini, and Nora Taranto report no disclosures.
Alex Chaitoff reports consultancy for Alosa Health
Kate Grant reports no disclosures.  

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