As lawmakers in Congress debate the merits of two GOP plans to repeal the Affordable Care Act, the report concludes that adults who have health insurance are between 71% and 97% less likely to die imminently than those who lack health insurance.
“Health insurance saves lives,” the authors wrote Monday in the Annals of Internal Medicine.
The report affirms, and updates, a landmark review conducted by the National Academies of Science’s Institute of Medicine in 2002. Research published since then “strengthens confidence” in the findings of the original report, wrote Dr. Steffie Woolhandler and Dr. David Himmelstein, both experts on public health at Hunter College in New York who support a national, single-payer health system.
Woolhandler and Himmelstein also found that adults with health insurance are in better health than their uninsured peers, have their hypertension under better control, and are less likely to suffer from depression.
Their report was published hours after the Congressional Budget Office said the Senate Republicans’ draft bill to repeal the Affordable Care Act would result in the departure of roughly 22 million Americans from health insurance rolls by 2026. The ACA repeal bill that passed in the House of Representatives would prompt 23 million Americans to become uninsured over the next decade, the CBO has said.
Himmelstein said Monday that, if the CBO’s forecast of the Senate bill’s effects is correct, an additional 29,000 Americans would die each year as a result. Instead of repeal, he said, lawmakers should “move forward” to make the Affordable Care Act a universal, single-payer system.
“Thousands of people are already dying each year because the Affordable Care Act has left 28 million uninsured,” said Woolhandler, an internal medicine physician in the South Bronx area of New York. “The Republican health reform bills would increase that death toll.”
Often citing the same studies as those reviewed in the new Annals of Internal Medicine article, some Republicans have asserted that health insurance saves no lives. Researchers who have plumbed the effects of insurance status on the health of individuals and populations disagree.
One group of those researchers called out Sens. Ted Cruz (R-Texas) and Raul Labrador (R-Idaho) last week for arguing that insurance coverage doesn’t improve health. That claim “is simply inconsistent with the evidence,” Harvard University’s Dr. Benjamin Sommers, Dr. Atul Gawande and Katherine Baicker wrote in the New England Journal of Medicine.
In a 2012 study reviewed in the new Annals report, Sommers and Baicker compared the health of Massachusetts adults during a 2006 expansion of insurance rolls with the health of adults outside the state, where coverage rates didn’t change. They found that for every 830 adults who gained health insurance under then-Gov. Mitt Romney’s 2006 universal healthcare initiative, one premature death per year was averted.
In addition, mortality decreased by 2.9% in Massachusetts relative to comparison counties outside the state. And poorer Massachusetts counties, as well as those that had lower-than-average coverage rates before the expansion, saw larger improvements in mortality after more people joined the insurance rolls.
Other studies cited in the Annals review followed populations over long periods to glean whether their insurance status was related to longer or shorter lives and better or poorer health. Though most of those studies were marred by methodological problems, they tended to suggest that adults with insurance live longer and are healthier than those without.
Woolhandler and Himmelstein also cited the findings of a randomized controlled trial — considered the gold standard of clinical research — that compared the health outcomes of two groups of low-income Oregonians. Some gained health coverage in 2008 through a newly created lottery for Medicaid slots and some did not.
In a year of follow-up, the death rate among those who won a lottery spot was lower — by 0.13 percentage points — than the rate for their peers who remained uninsured.
Many point to that statistically insignificant finding to argue that cutting Medicaid rolls — as both the House and Senate bills would — would not harm the public’s health.
But Woolhandler and Himmelstein countered that such an underwhelming finding was no surprise given the youth of the populations studied (very few in either group died), the brevity of the follow-up, and the fact that many lottery losers ended up getting coverage by other means.
The pair pointed to the clinical trial’s other findings to suggest that insurance had a significant effect on the health of adults who got it. After gaining a slot in Oregon’s lottery, winners rated their health as better, which is generally considered a telling barometer of someone’s actual health status. Lottery winners were more likely to have diabetes diagnosed and treated with medication, and were much less likely to screen positive for depression.
Those with Medicaid coverage had slight reductions in their blood pressure readings too, but those findings weren’t considered robust enough to be reliable.
Other studies have strongly suggested that more insurance coverage brings better control of high blood pressure. In an experiment reported by the Santa Monica-based Rand Corp. in 2003, patients with high blood pressure who didn’t have to pay deductibles reduced their hypertension far more substantially than did patients who were randomly assigned to plans that required cost-sharing. The effect was more pronounced among low-income study participants than it was in those with high incomes.
Dr. John Michael McWilliams, a Harvard public health researcher who was not involved in the Annals review, called it a “good update on the literature” that should remind policymakers of some basic facts.
“We know that expanding coverage does a lot of good things for the uninsured, so coverage is bound to have a beneficial effect on health outcomes. We just can’t measure the magnitude of those effects very well,” he said. ”And it seems very odd to acknowledge that insurance improves access to a lot of the things that keep you alive, but then argue that it has no effect on mortality.”
The study looked at non-elderly women in Tennessee after the state started scaling back its Medicaid rolls in 2005. It compared the stage of diagnosis and the prevalence of treatment delays for breast cancer patients who were probably affected by the policy shift with those of more affluent women who would not have been affected.
After the Medicaid retrenchment, affected women were more likely to have their breast cancers diagnosed at a later, more dangerous stage, and to receive delayed treatment for their cancer than women not affected by the shift. Though the study did not look at breast cancer deaths, its authors noted that prognosis generally improves with earlier detection and treatment, and that higher mortality among poor women is a likely result of contractions in Medicaid coverage.
MORE IN SCIENCE