Health care took center stage on both nights of the most recent Democratic debates, a reminder of how worried Americans are about getting and affording health care. Their concerns are not unfounded. More than 30 million do not have health insurance, which puts them at greater risk of illness, and possibly death. A new study from the National Bureau of Economic Research shows that 15,600 deaths between 2014 and 2017 could have been avoided if all states expanded Medicaid.
These findings add to a growing body of research that shows insurance coverage saves lives. In 2002, a landmark report from the Institute of Medicine (IOM) estimated that 18,000 Americans died in 2000 because they were uninsured. Subsequent research has continued to confirm the link between insurance and mortality. Using IOM’s methodology, the Urban Institute estimated that 137,000 people died between 2000 and 2006 because they lacked health insurance.
Low-income Americans have historically had a high uninsured rate. The expansion of Medicaid under the Affordable Care Act (ACA) was designed to make health coverage accessible to people — many of whom are employed — who don’t earn enough to afford health insurance. Even before the ACA, researchers identified expanding adult Medicaid eligibility as a way to reduce mortality. In New York, Maine, and Arizona, Medicaid expansions were associated with a significant reduction in adjusted all-cause mortality (by 19.6 deaths per 100,000 adults, for a relative reduction of 6.1%) compared with states that did not expand Medicaid eligibility.
Similar benefits were seen after the ACA’s expansion provisions went into effect. Among patients with end-stage renal disease, those that lived in a state that expanded Medicaid were less likely to die in the next year.
Since the ACA became law, nearly 20 million Americans have gained coverage. Insurance rates are at the highest levels in our country’s recent history. But 14 states have not yet expanded Medicaid. Even among those who are insured, there is a question of whether their insurance coverage protects them adequately. Twenty-three percent of U.S. adults ages 19 to 64 — or 44 million people — are inadequately insured because their out-of-pocket costs and deductibles are too high relative to their income. In addition, Congress and the Trump administration have taken several steps to roll back coverage gains made under the ACA, including eliminating the tax penalty for not purchasing insurance and allowing insurers to sell limited health insurance plans. These plans are not required to cover essential benefits or comply with other insurance standards and may undermine the stability of state insurance risk pools.
Insurance coverage is necessary but not sufficient to guarantee that all Americans have access to the health care they need. Other barriers to access persist, including uncovered services and inadequate supply of providers. There is a shortage of providers in rural parts of the country; almost 100 rural hospitals have closed since 2010 and hundreds more are at risk of closure. When lifesaving medical treatment is too far away to get to in a timely fashion, insurance coverage alone does not ensure access to care.
Nevertheless, insurance coverage protects people from illness and death. Policymakers exploring different options for health reform can legitimately view insurance as a public health program, like vaccination or blood pressure control — that saves thousands of lives. The 2020 presidential candidates should consider this perspective as they debate different approaches to reform our health system.
