In a new analysis published this week in the American Journal of Public Health, a pair of doctors who advised Sanders's presidential campaign found that a repeal of the law without a replacement could cost anywhere from 14,000 to 60,000 lives — in the next year alone.
It's unsurprising that partisans arguing over what to do with the law — known officially as the Affordable Care Act — would disagree about the effect's of repealing it. But even nonpartisan health policy experts are at a loss when asked for a figure on how many people would perish if the ACA comes off the books.
That's because the law's most widespread feature is helping people buy health insurance, and the link between being covered by health insurance and actually being healthier is not fully understood.
It isn't that the question hasn't been studied or that individual benefits of health insurance aren't known. An Institute of Medicine report in 2009 rounded up the evidence that uninsured people fared worse after a heart attack, stroke, cancer, diabetes, congestive heart failure and trauma. But what does all that harm add up to in lives lost or saved?
To make their estimate, physicians Steffie Woolhandler and David Himmelstein extrapolated from a handful of studies published during the past 15 years that used a variety of data sets and situations — such as the expansion of Medicaid in Oregon through a lottery and the effects of health reform in Massachusetts.
“The common sense belief that if you lose your health insurance, it’s going to make your health worse and it might even kill you — that's a common-sense belief that happens to be true,” Woolhandler said in an interview. “People cannot say we’re going to take health care away from 24 million people and say nobody’s going to die.”
But health is a cumulative, complex and long-term outcome, determined not only by health insurance status, but by socioeconomic factors, genetics, lifestyle and the neighborhoods where people live. The differences between having insurance and not having insurance often encapsulates a broad swath of other factors that affect people's well-being.
“When you ask the question, then, what would be the effect of repealing the ACA, there’s no perfect way to answer this question,” said Benjamin Sommers, an associate professor of health policy and economics at the Harvard T.H. Chan School of Public Health.
One of the studies the researchers drew on to make their estimate was led by Amy Finkelstein, an economist at the Massachusetts Institute of Technology. Finkelstein said that the body of research, including her work on the effects of the 2008 Medicaid expansion in Oregon, have made her confident that health insurance improves health. That study found a significant drop in depression and an increase in people's self-reported health among those who randomly received Medicaid compared with those that did not.
But receiving insurance did not lead to improvements in other areas, such as better management of blood pressure, cholesterol levels or blood sugar control over the two years of the study. And since death was — fortunately — a relatively rare event for people between the ages of 19 and 64 in the Oregon study, where the survival rate was higher than 99 percent, measuring the effect of insurance on mortality may not be the right way to make the case it was working.
“You can’t rule out that Medicaid saves a bunch of lives, but you also can’t rule out that it kills a bunch of people,” Finkelstein said of the Oregon data. She argued that while health insurance is aimed at improving health, it is also fundamentally a product aimed at protecting people against financial ruin, and another way to measure its effects — particularly in the short term — would be to examine how it helped financial security.
The Oregon study showed reductions in financial strain, and a working paper published last year estimated that people who gained coverage through the broader Medicaid expansion had anywhere from a $600 to $1,000 reduction in collection debt.
Sommers, whose work was also used to estimate the effect of ACA repeal, said that another challenge is knowing whether giving someone insurance — which is what happened in his study of health reform in Massachusetts — will have directly the opposite effect as taking it away.
Two of the studies the researchers cited examined large data sets and found an association between longer life and having health coverage, but could not determine that the insurance drove the effect. That leaves open the possibility that it isn't coverage itself that caused the disparity, but might also be explained by other differences between people who have insurance and those who don't.
In his work, Sommers compared the death rates of people in Massachusetts before and after the state implemented health reform in 2006 with people in similarly matched counties that did not expand insurance coverage. He found a decrease in deaths in Massachusetts — in just the kinds of deaths, such as cancer, diabetes, heart disease that they expected might shift due to access to insurance.
“The short answer is, these are challenging extrapolations,” Sommers said. “But I think what’s fair to say, based on our studies, is that giving people insurance can reduce mortality, so likely taking it away will cause an increase. ... The exact number is much harder to pin down.”