I’m getting pretty tired of hearing the continual beating of the drums warning of how many deaths will result from the Repeal of Obamacare. Also, the CBO evaluation is predicting the huge numbers of people without health insurance.
But what are the real numbers?
Lori Robertson and Robert Farley reported that House Minority Leader Nancy Pelosi has said, “hundreds of thousands of people will die” if the Senate health care bill becomes law. But what does the research say about the impact of health insurance on mortality rates?
There are several studies backing up the idea that those who lack health insurance have a higher chance of dying prematurely than those with insurance, as they found when they looked at this issue in 2009.
But the research uses terms like “could” and “suggests” and “cannot definitively demonstrate a causal relationship,” not the definitive “will” favored by opponents of the bill. We can’t say whether any specific projection is a correct or valid number.
Democrats have made this a talking point. “We do know that many more people, hundreds of thousands of people, will die if this bill passes,” Pelosi said on CBS This Morning on June 26. In a July 2 interview on CNN’s State of the Union, Sen. Bernie Sanders said “tens of thousands of people every single year will die” if the Affordable Care Act were repealed entirely, without a replacement.
Later in that interview, Sanders said that “no one knows exactly the number” but that one study said, “up to 28,000 people a year … will die” from the increase in the uninsured under the Republican bills. He and Pelosi are referring to an analysis by the left-leaning Center for American Progress.
We’ll explain how that study reached its conclusions, as well as what other research has found.
The analysis by CAP concluded that if coverage losses in the Senate bill mirrored losses in the House bill, then the legislation “would result in 217,000 additional deaths over the next decade.”
At the time Pelosi made her statement, the Congressional Budget Office hadn’t yet released its analysis of the Senate’s Better Care Reconciliation Act, but it did later in the same day. The CBO concluded that the Senate bill would increase the number of uninsured by 22 million in 2026, compared with current law. The CBO’s estimate for the impact of the House health care bill, the American Health Care Act, had been 23 million more uninsured in 2026, compared with current law.
Using the 23 million figure from CBO and a study on mortality in Massachusetts after it passed sweeping health care changes in 2006, the CAP report extrapolated that “the coverage losses from the Senate bill would result in 27,700 additional deaths in 2026” and 217,000 over 10 years.
A professor of social epidemiology and two graduates of the Harvard T.H. Chan School of Public Health, as well as two CAP staffers wrote the CAP report. (The Harvard researchers later gave updated figures for the Senate bill — 26,500 extra deaths in 2026 and “208,500 unnecessary deaths” over a decade.)
The CAP report has limitations, which the authors acknowledged. And its specific figures are the midpoint of a range. There’s a 95% confidence interval associated with the 27,711 excess deaths estimate, meaning, “we are 95 percent confident that the true number of annual excess deaths will be between 9,583 and 46,000,” the authors explain.
What are the limitations to those numbers? The CAP report took a study about Massachusetts and applied it to the entire country, and it took a study about the impact of increasing those with insurance and applied it to the opposite scenario — the number with insurance declining under the GOP health care bills.
The Massachusetts study, published in the Annals of Internal Medicine in May 2014, compared changes in mortality rates for adults age 20 to 64 in the state from 2001 to 2005 and 2007 to 2010 to a control group of counties in other states. Massachusetts passed health care legislation in 2006, often called Romneycare, that was similar in many ways to the federal Affordable Care Act, passed in 2010.
The conclusion of the Massachusetts study: The state’s health care law was associated with a decrease in deaths. The study showed that “The Massachusetts 2006 health care reform was associated with significant reductions in all-cause mortality over 4 years of follow-up relative to a control group of similar counties in states without reform. Reductions were concentrated in causes of death that were more plausibly amenable to health care and in populations most likely to benefit from expanded access, particularly residents of counties with lower incomes and higher pre-reform uninsured rates.”
The authors found a drop in mortality of 8.2 per 100,000 adults and said that — along with an increase in insurance coverage in the state — implied for “approximately every 830 adults who gained insurance, there was 1 fewer death per year.”
The CAP report simply did the math — applying that finding to the country at large using the CBO’s estimates for the increase in the uninsured under the GOP bills.
The lead author of the Massachusetts study, Benjamin D. Sommers, an associate professor of health policy and economics at Harvard, told us the CAP report was “a reasonable attempt to project mortality effects based on prior research.”
“The authors do mention some of the main limitations of this approach that I also would have pointed out — namely, that Massachusetts is of course not identical to the U.S. as a whole, and withdrawing coverage may not have produced mirror image effects as expanding coverage,” Sommers said.
The Massachusetts study noted that the state differed from the rest of the country in many ways, including having lower mortality, higher income and the highest per-capita number of physicians. “The extent to which our results generalize to the United States as a whole is therefore unclear,” the authors wrote.
“But the ACA was modeled after Massachusetts health reform, so I do think it’s probably the best gauge we have for this projection,” Sommers said. “It’s hard to pin down any specific number with certainty, but I think the CAP projections are at least plausible.”
Sommers said he would use less definitive language than the politicians. He said Pelosi was “taking what is a reasonable projection and stating it as a fact; I would have used the caveats above and been a bit less definitive — but I’m a researcher not a politician!”
There are also limitations to the study on Massachusetts, as with most studies. It’s difficult in research to prove causality — that one thing directly causes another — and that was the case here. The authors noted, “We do not have individual-level insurance information and thus cannot directly link mortality changes to persons gaining insurance coverage.” They said it was possible that the reduction in mortality was caused by other factors in the state, though the study controlled for economic measures and didn’t find that mortality similarly declined for elderly adults in the state — who would have been covered by Medicare and largely unaffected by the health care changes.
Other research by Brendan Saloner, an assistant professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, states that told “no single study is as good as looking at the full body of research.” And while not all studies have found health improvement related to insurance coverage, the “preponderance of studies, especially the well-done studies, find that gaining insurance coverage, especially for low-income people, improves health and reduces mortality risks.”
Let’s look at some of the research:
- A 2017 review of studies over the past decade — published in the New England Journal of Medicine with Sommers as the lead author — concluded: “Insurance coverage increases access to care and improves a wide range of health outcomes. Arguing that health insurance coverage doesn’t improve health is simply inconsistent with the evidence.” On the specific issue of whether coverage saves lives, the review described three recent studies, including the Massachusetts study. We’ll describe the other two, on Medicaid expansion, below.
- A 2012 study published in the New England Journal of Medicine, also with Sommers as the lead author, compared three states that substantially expanded Medicaid (before the Affordable Care Act) to neighboring states that did not expand Medicaid. It concluded, “State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.” The study looked at five years before and after expansions of Medicaid eligibility in New York, Maine and Arizona. Among the limitations: “We examined three expansion states, and the results are largely driven by the largest (New York), so our results may not be generalizable to other states.”
- The Oregon Health Insurance Experiment, published in the New England Journal of Medicine in 2013, provided mixed results. The study, whose lead author, Harvard’s Katherine Baicker was a coauthor on the two studies above, compared data from 6,387 adults who were able to apply for Medicaid coverage in Oregon through a lottery drawing to 5,842 adults who were not selected. The authors concluded: “This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.”
The study measured three health indicators — blood pressure, cholesterol and glycated hemoglobin levels (which measure diabetic blood sugar control) — over a two-year period. The time period studied was among its limitations; it said “the effects of insurance in the longer run may differ.” The study didn’t address mortality rates; an earlier working paper on the first year of the Oregon experiment said “not surprisingly” researchers didn’t see “any statistically significant improvement in survival probability” during the short time frame with few deaths.
- A 2014 study published in the Journal of Clinical Oncology looked at cancer diagnoses among 39,447 people age 20 to 40 between 2007 and 2009 and concluded that “young adults who are uninsured may be more likely to present with metastatic disease, be undertreated, and die after a diagnosis of cancer relative to those who are insured.”
- A 2017 study in the journal Medical Care determined that the provision in the ACA allowing young adults to stay on their parents’ plan until age 26 “was associated with a 6.1% decline in monthly disease-related mortality” and no significant difference in external-trauma mortality, such as from accidents. The study compared mortality in 19- to 25-year-olds to that of a control group of 26- to 30-year-olds in 2008-2013.
- Among older research: A 2004 study published in Health Affairs found that the uninsured among those age 55 to 64 had a 3% higher risk of dying over an eight-year period, calculating that 13,000 yearly deaths “may be attributable to the present lack of insurance coverage among the near-elderly.” It used data from the Health and Retirement Study, sponsored by the National Institute on Aging, and controlled for socioeconomic factors.
- In March 2009, Dr. John Z. Ayanian of the National Academies’ Institute of Medicine testified to Congress on the review by the Committee on Health Insurance Status and Its Consequences of nearly 100 studies released since 2002. He described the uninsured as being more likely to delay or forgo preventive care, medications and treatment. His written testimony said: “Uninsured adults are also more likely to be diagnosed with later-stage cancers compared to their insured peers. If hospitalized for a serious acute condition, such as a heart attack, stroke, or major trauma, uninsured adults are more likely to die after admission to a hospital. Uninsured adults are 25 percent more likely to die prematurely than insured adults overall, and with serious conditions such as heart disease, diabetes or cancer, their risk of premature death can be 40 to 50 percent higher. Fortunately, our Committee also found good news to report: when uninsured people acquire health insurance they can experience both immediate and long-term improvements in their health.”
- In 2002, the Institute of Medicine, drawing on previous research that found a higher mortality risk for the uninsured, determined that 18,000 nonelderly adults died because they lacked health insurance in 2000. A 2009 study, published in the journal Health Services Research and authored by Richard Kronick, who later headed the Agency for Healthcare Research and Quality, said that finding was “almost certainly incorrect.” Kronick’s study found no difference in mortality between the uninsured and those with employer-sponsored insurance after adjusting for demographic, health status and health behavior factors.
This body of research looked at the impact of already being uninsured, or the impact of gaining coverage. The CAP report, as we noted, examined the opposite situation — declining insurance coverage.
That’s a challenge in applying past research to the proposed health care legislation. “We’ve never seen large scale reductions in insurance coverage” such as those projected by the CBO, Johns Hopkins’ Saloner notes.
The 2017 review of studies in the New England Journal of Medicine noted that critics of the ACA have contended that benefits from insurance gains depend on the type of coverage — that Medicaid coverage isn’t beneficial, while private insurance is. (That’s one argument in a February paper published by the conservative Manhattan Institute that said the “best statistical estimate” for lives saved by the ACA was “zero.”)
“But there is no large quasi-experimental or randomized trial demonstrating unique health benefits of private insurance,” the NEJM review said. It said that “further research is needed to assess the relative effects of various insurance providers and plan designs.”
The Congressional Budget Office projects that the Senate health care bill would increase the number of uninsured Americans by 22 million in 2026 — a figure that both sides in the debate are distorting:
Sen. Bernie Sanders wrongly claims the bill “would throw 22 million Americans off of health insurance.” Actually, some would prefer not to buy insurance. In fact, CBO estimates that 15 million more would be uninsured next year alone “primarily because the penalty for not having insurance would be eliminated.”
Conversely, House Speaker Paul Ryan says of the 22 million, “It’s not that that people are getting pushed off our plan. It’s that people will choose not to buy something they don’t like or want.”
That’s inaccurate, too. Under the bill, some would no longer be eligible for Medicaid and others would not be able to afford coverage.
The White House sought to discredit the CBO estimate, tweeting that the agency’s analysis of the Affordable Care Act in 2010 was off by “100%.” The “CBO estimated that 23M would be covered in 2017,” the tweet said. Actually, CBO was pretty close. The number of people without insurance has declined by 20 million since 2010.
On June 22, Senate Republicans introduced the Better Care Reconciliation Act — their version of legislation to repeal and replace the Affordable Care Act, which was signed into law by former President Obama in 2010. As with the House version, CBO projected a sharp increase in the number of people without insurance, compared with current law.
In a report issued June 26, CBO and the Joint Committee on Taxation said the Senate bill “would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation.” CBO estimated an increase of 23 million under the House bill.
“By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law,” CBO said.
As we saw with the CBO estimate of the House bill, both sides distorted what CBO said about the increase in the number of uninsured. (See “The 24 Million Talking Point” and “Spinning the CBO Report.”)
Shortly after CBO released its report, Sen. Bernie Sanders went to the Senate floor and spoke about the agency’s analysis of the bill. “According to CBO, and that report just came out a few hours ago, this bill would throw 22 million Americans off of health insurance …”
A day later, House Speaker Paul Ryan appeared on Fox & Friends and gave a different spin on the 22 million figure in the CBO report (at about the 36-second mark of the video). “What they’re basically saying at the Congressional Budget Office is if you’re not going to force people to buy Obamacare, if you’re not going to force them to buy something that they don’t want, then they won’t buy it. So it’s not that that people are getting pushed off our plan. It’s that people will choose not to buy something they don’t like or want.”
In fact, CBO said it’s a combination of both: some people being thrown off and others opting not to buy insurance they don’t like or want.
The biggest jump in the number of uninsured Americans under the Senate bill would occur in the first year and largely because, as Ryan says, people who were forced to buy health insurance would opt not to purchase it. The Senate bill eliminates a tax penalty for not having insurance. For tax year 2016, the tax was $695 or 2 percent of your income, whichever is higher. “CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law — primarily because the penalty for not having insurance would be eliminated.”
In particular, CBO says healthier people would leave the market, driving up premiums in the short-term. “Under the Senate bill, average premiums for benchmark plans for single individuals would be about 20 percent higher in 2018 than under current law, mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up,” CBO says.
However, the CBO said it didn’t expect the elimination of the requirement to have insurance to affect those now with Medicaid. “The agencies do not expect that, with the penalty eliminated under this legislation, people enrolled in Medicaid would disenroll,” CBO report said.
CBO expects there would be “15 million fewer Medicaid enrollees by 2026 than projected under current law. The decline would be, in large part, due to proposed Medicaid changes contained in the Senate bill — which reduces Medicaid spending by $772 billion by 2026.
The ACA expanded eligibility to all individuals under age 65 who earn up to 138 percent of the federal poverty level, and the federal government currently pays 95 percent of the cost for the expansion population. But, under the Senate bill, states that already have expanded Medicaid would get reduced federal funding, beginning in 2021. And states that haven’t yet expanded eligibility could only do so at their standard federal match rates, which average 57 percent.
“Some of that decline would be among people who are currently eligible for Medicaid benefits, and some would be among people who CBO projects would, under current law, become eligible in the future as additional states adopted the ACA’s option to expand eligibility.”
Also, federal Medicaid payments to states would no longer be open-ended. The bill would cap the amount of federal funding that states can receive per Medicaid enrollee, beginning in fiscal year 2020. That would “shift a greater share of the cost of Medicaid to states over time” and force states to adopt a mix of cost-saving options, including cutting benefits, eliminating optional services and restricting eligibility for enrollment, CBO says.
For those buying insurance on the individual market, CBO says some who would otherwise be insured under current law would be discouraged from buying it under the Senate bill. For example, CBO says that “few low-income people would purchase any plan,” because the cost would be prohibitive. “Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income — also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.”
CBO says that the increase in the number of uninsured “would be disproportionately larger among older people with lower income — particularly people between 50 and 64 years old with income of less than 200 percent of the federal poverty level.” For example, CBO says that single individuals who are 64 years old and earn $26,500 (175 percent of federal poverty level) would have to pay $6,500 in net premiums for a silver plan after receiving a government tax credit — $4,800 more than they would under current law.
On the day that CBO released its report on the Senate bill, the official White House Twitter account posted a tweet that was critical of CBO’s past estimate on the Affordable Care Act. In particular, the White House criticized CBO’s projection for the number of nonelderly people (under age 65) that would be covered by the ACA.
FACT: when #Obamacare was signed, CBO estimated that 23M would be covered in 2017. They were off by 100%. Only 10.3M people are covered.
Let’s set aside the obvious math error. The difference between 23 million and 10.3 million is 55 percent, not 100 percent.
More important, the White House tweet says — as administration officials have said in the past — that CBO was wrong about the number of people who would be insured by the Affordable Care Act. But, as we wrote, CBO was actually pretty close to accurate on the overall number of people who would gain insurance under the law. What CBO got wrong was the mix of insured: There were more people who gained insurance through the Medicaid expansion than CBO expected, but fewer people that obtained coverage through the ACA exchanges.
To briefly recap: CBO issued its official estimate of the cost and effects of the Affordable Care Act on March 20, 2010, and then updated its estimates in July 2012 after the Supreme Court ruled that states could not be forced to expand eligibility for Medicaid.
In its 2012 report, CBO projected that there would be 30 million uninsured people under 65 years old in 2016. The actual number was 28.2 million in 2016, according to the latest figures from the Centers for Disease Control and Prevention’s National Health Interview Survey. The number of uninsured fell from 48.2 million in 2010 to 28.2 million in 2016.
The graphic that was attached to the White House tweet ignored the fact that the number of people without insurance declined by 20 million since 2010. Instead, it focused on the number of people who purchased insurance on the insurance exchanges created by the ACA.
CBO estimated that in 2016 there would be 23 million getting policies through ACA exchanges. The actual number was 10.4 million during the first half of the year, according to the Centers for Medicare & Medicaid Services.
However, that’s just half the story. CBO underestimated the number of people who would enroll in Medicaid under the expansion of the health care program for low-income Americans.
CBO projected that 10 million people would enroll in Medicaid by 2016. But 14.4 million adults had enrolled in Medicaid through March 2016 as a result of the Affordable Care Act’s expansion of the program, according to an analysis by the nonpartisan Kaiser Commission on Medicaid and the Uninsured.
But what all the numbers are missing is that many of the states are already “adapting to the possible changes in Medicaid. There is soo much inefficiency and fraud. More and more states are seeking changes to their programs. Indiana and Maine, for example, are among states that have proposed work requirements for able-bodied adults in the program. (Indiana estimates that a quarter of those required to work won’t and “will have HIP [Medicaid] eligibility suspended until compliance has been demonstrated.”) States say that by making Medicaid contingent on work, potential beneficiaries will be incentivized to find jobs that offer health insurance.
Wisconsin is asking the federal government to approve a drug-testing requirement, saying it will help get people into treatment and prepare them for jobs. Arizona wants to cap the amount of time certain nondisabled adults can remain on Medicaid to five years, taking a page from the welfare reform playbook of the 1990s. And Utah is proposing a limit on the number of adults without dependent children who can enroll in its Medicaid program.
Such requests are popping up all across the country, according to a recent analysis by the Kaiser Family Foundation, a nonprofit think tank.
So far, the Trump administration hasn’t approved any of these requests, but it signaled in a letter to governors in March that it would be more flexible than the Obama administration, which did not approve requests from Indiana and Arizona in the past.
“We commit to ushering in a new era for the federal and state Medicaid partnership where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population,” wrote Health and Human Services Secretary Tom Price and Verma.
People dying after Obamacare “is repealed”, yes, but not because people are losing their health care insurance. Many didn’t want or still can’t afford health care coverage because of high premiums and very high dedutibles. They will still die, but everyone forgets that due to many long term regulations patients can not be refused care in an emergency situation and will continued to be cared for. Let’s stop beating the drums of catastrophe and start working for a bilateral solution to the health care crisis!!
Next I will discuss how the Senate health care bill will affect the Insurance industry and the rest of us!