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Affordable Care Act, Culture, Government, Government Programs, Health Care, Health Care Reform, Health Disparities, Health Insurance, Health Reform, Healthcare, Inequality, Media, Obama, Obamacare, Politics, Public Health, Public Policy, Social Justice, Society, Uncategorized, Women's Health

Powerful New Study Shows That The Affordable Care Act Could Save A Lot Of Lives… Read This To Make Sure You’re Prepared For The Right-Wing Backlash

PreventableDeaths

Fewer people died in Massachusetts after the state enacted its landmark legislation to cover the uninsured, according to a new Harvard University study that could have major implications for the effects of the Affordable Care Act.

A Harvard team compared the mortality rates in Massachusetts before and after then-Gov. Mitt Romney (R) signed the health care reform bill into law in 2006 with the mortality rates in similar counties in other states during the same time periods. Based on their calculations, the mortality rate declined 2.9 percent overall among adults 20 to 64 years old after the law went into effect — which translates into 8.2 fewer deaths per 100,000 people. So-called ‘Romneycare’ served as a model for President Obama’s Affordable Care Act.

The analysis, which was published by the Annals of Internal Medicine Monday, is the latest attempt by researchers to prove the seemingly obvious relationship between health coverage and the access to medical care it brings with improved health and longer lives. In spite of this intuitive connection, there remains intense political controversy about whether being uninsured consigns people to poorer health and shorter lives (below, I’ll address the ‘controversy,’ which is — not surprisingly — based on rhetoric, not science).

Researchers led by physician and economist Benjamin Sommers of the Harvard School of Public Health didn’t attempt to provide a definitive answer to these larger questions — no one study can do that. However, they did conclude that the lower mortality rate they observed appears to be real, even if its national implications are uncertain amid the reduction in the number of uninsured people brought about by the Affordable Care Act.

“We find a significant reduction in mortality among nonelderly adults in Massachusetts since its 2006 reform relative to a control group of similar counties in states without such reforms. Although this analysis cannot demonstrate causality, the results offer suggestive evidence that the Affordable Care Act — modeled after the Massachusetts law — may impact not only coverage and access but also mortality,” the report says.

“The extent to which our results generalize to the United States as a whole is therefore unclear, which underscores the need to monitor closely the Affordable Care Act’s effect on coverage, access, and population health across all states,” Sommers and his co-authors wrote.

The researchers emphasized that their findings cannot prove that expanding health insurance coverage led directly to lower mortality, and noted that they did not have access to information about specific, individual cases. Researchers used data in Massachusetts and elsewhere in the county from the federal Centers for Disease Control and Prevention and the U.S. Census Bureau to create their comparisons.

The effects of expanding coverage in Massachusetts appear more significant when narrowed down to health problems that can be treated or prevented when individuals have access to medical services. The researchers found the mortality rate for people with these “causes amenable to health care” — including issues like cancer, infections and cardiovascular disease — decreased by 4.5 percent in Massachusetts after Romneycare when compared to counties with similar populations. And the connection between expanded coverage was even stronger among people who live in counties with lower income and higher rates of uninsurance, the report says.

Unadjusted mortality rates for adults aged 20 to 64 years in Massachusetts versus control group (2001–2010). The shaded band designates the beginning of the Massachusetts state health care reform that was implemented starting in July 2006.

Unadjusted mortality rates for adults aged 20 to 64 years in Massachusetts versus control group (2001–2010).
The shaded band designates the beginning of the Massachusetts state health care reform that was implemented starting in July 2006. (Sommers, Long, & Baker, 2014; Annals of Internal Medicine)

As Adrianna McIntyre pointed out in a column published earlier today, “[i]f you think the study’s primary findings are impressive, consider their implications: ‘mortality amenable to health care’ does not just magically decline. If fewer people are dying, that is almost certainly because diseases are being better treated, managed, or prevented—because of improved health. It’s hard to come by data on objective measures of health at the state level, but the ‘improved health’ story is consistent with other findings in the paper: individuals had better self-reported health, were more likely to have a usual source of care, received more preventive services, and had fewer cost-related delays in care.”

Applied nationwide, the results of the Harvard analysis indicate that the impact of the Affordable Care Act would be even more significant than we previously though. According to the Congressional Budget Office, the Affordable Care Act will reduce the number of uninsured people by 12 million this year and by 26 million as of 2017.

To put that into context, that’s equal to one death prevented for every 830 who gain health insurance. Based on the CBO estimates, the Affordable Care Act could prevent a staggering 31,325 deaths in the next three years. 

That’s hugely important. 

Of course, you know what that means: these findings will almost certainly be criticized by opponents of health care reform, who routinely deny the scientific evidence demonstrating the importance of health insurance. So in the spirit of prevention, let’s go ahead and refute those claims…

The Costs of Being Uninsured

Past research in this area has demonstrated an unquestionable link between lack of health insurance and mortality — the only debatable issue is whether or not the relationship is causal. In 2002, the prestigious Institute of Medicine issued a report concluding that 18,000 people died in 2000 because they had no health insurance. Six years later, the Urban Institute duplicated the IOM study with new data and reported that 22,000 people die each year because they have no health insurance. Even more recently, a team of researchers at Harvard Medical School and Cambridge Health Alliance published a study concluding that nearly 45,000 annual deaths are attributable to lack of health insurance.

Based on the most recent data, one American dies every 12 minutes from lack of health insurance.

The impact of being uninsured affects certain populations more than others. The risk of death is approximately 40 percent higher for the average uninsured American — but for those in fair or poor health, being uninsured increases the risk of death by a staggering 222 percent.

Critics who claim that no such relationship between health insurance and mortality exists generally rely on one of two lines of reasoning to make their argument. The first is that the potential iatrogenic effects of health care (i.e., illnesses, injury, or other adverse events caused by medical treatment or medications) cancel out the benefits of having access to health care. The second argument, one that Mitt Romney made during the 2012 presidential elections, is that no one dies from lack of health insurance because federal law (the Emergency Medical Treatment and Active Labor Act) requires hospitals to provide emergency care to anyone who needs it regardless of citizenship, legal status, or ability to pay. Both of these arguments, however, are deeply flawed and do not stand up against basic scrutiny, not to mention scientific evidence. Let’s take a look at that…

The claim that medical care does ‘more harm than good’ was featured prominently in a 2010 article in The Atlantic The author of the piece, Megan McCardle, argues that providing people more access to health care will cause just as much harm as benefit, making it a wash whether one is insured or not. But there are several huge problems with McCardle’s line of reasoning, which is also popular among those who scoff at “conventional medicine.” Dr. Harriet Hall, a retired family physician and former U.S. Air Force flight surgeon, wrote a great article debunking the “death by medicine” argument, and I’ll briefly go over some of the main points. First and foremost, while medical procedures and medications can certainly have adverse consequences, most of them are quite minor when compared to the benefits they provide. As Dr. Hall points out, many adverse drug reactions “are transient minor annoyances like a rash.” And even for more serious side reactions, the positive effects of the medication far outweigh the potential side effects. “An insulin reaction counts as an adverse drug reaction, but if the patient weren’t taking insulin he probably wouldn’t be alive to have a reaction,” writes Dr. Hall. The same is true for medical procedures like surgery, which Dr. Hall points out in this example: “People have iatrogenic infections in the hospital, for instance post-op infections; but without hospitalization and surgery they might have been dead instead of infected.”

So that’s one problem with McArdle’s argument — the potential harm caused by medical care is not nearly as severe as the negative health implications of going without health care. While a drug reaction or a hospital-acquired infection is certainly not pleasant, the alternative is to die from not having access to necessary medications or surgical interventions.

A second flaw in this line of reasoning is that there is no attempt to account for the quality of care or the training of those providing care. Many iatrogenic effects are not caused by the medical procedure itself, but rather the negligence of those delivering it. As Dr. Hall points out, things like bedsores and malnutrition in nursing homes are included as “negative consequences” of health care, when in reality they are the result of untrained and/or uncaring health care providers.

Another problem with McArdle’s argument, in particular, is that she cherry-picked the research she included in her article, selecting one thirty-year-old study that stands out as an outlier in the literature. But that was the one study that showed the results she wanted, so she presented that as evidence to back up her claims while dismissing a huge body of evidence that contradicts those findings.

While medical errors and adverse reactions are certainly real issues, it is fallacious to suggest that the harm caused by health care — which is usually quite minor — is comparable to the consequences of not having access to health care at all. And it’s impossible to make a valid comparison, as we have no way of knowing whether or not people who suffer negative side effects from medical care would even be alive to experience those side effects if they couldn’t get that care in the first place.

The second argument, which Mitt Romney used to justify his opposition to the Affordable Care Act, is that people can’t possibly die from being uninsured because hospitals are required to provide emergency care to those who need it. Again, there are several major flaws with this line of reasoning. First, although hospitals cannot legally refuse to provide care to someone in an emergency situation, there are no legal requirements for the type or quality of care that must be provided. Emergency rooms are not equipped to treat complex conditions; all they can do is to treat the acute problem. If you have a heart attack, the ER will stabilize you and treat you until you are well enough to leave the hospital — but they won’t arrange your monthly medications or cardiology appointments once you leave. If you have an underlying heart condition, the care you receive at the ER won’t do anything to change that, so you are at risk of having another heart attack. Sure, you could go back to the ER when you have a second heart attack — but that’s assuming you don’t die before you get there.

An even bigger problem is that people without health insurance usually don’t get to a hospital until their medical condition has reached an advanced stage. Many poor and uninsured individuals wait far too long to seek medical care for problems that could have been treated if they had access to care when they first became symptomatic, but by the time they get to a doctor, the disease has already progressed too far. For example, low-income women without health insurance are significantly more likely to be diagnosed with later-stage or terminal breast cancer than women with insurance. Since the vast majority of uninsured women don’t get routine mammographies, the first sign that something is wrong is usually a noticeable lump. But by the time a lump becomes large enough to detect, the cancer has already started to progress. Further, even after detecting a problem, uninsured women are significantly more likely to delay seeking medical care because of the cost. This explains why mortality rates for breast cancer are so much higher among poor and uninsured women.

A final flaw in this line of reasoning is that there is no consideration of the benefits of preventive care. How many fewer people would die from things like heart disease, stroke, or kidney failure each year if they had access to routine medical care before they even developed the problem? We can’t put a number on it, but there is no question that skipping out on preventive care is at least an indirect cause of mortality for those without health insurance.

Dr. J. Michael McWilliams, MD, PhD, Assistant Professor of Health Care Policy and Medicine at Harvard Medical School and an associate physician in the Division of General Medicine at Brigham and Women’s Hospital commented on this issue, saying that although the science can’t ever be exact, it is conclusive:

“How many lives would universal coverage save each year? A rigorous body of research tells us the answer is many, probably thousands if not tens of thousands. Short of the perfect study, however, we will never know the exact number.”

Too Little, Too Late

The results of the 2002 Institute of Medicine study that I mentioned previously provide a clear explanation of the mechanisms by which lack of health insurance leads to morbidity and mortality. In fact, the title of the second report in the six part series is “Care Without Coverage: Too Little, Too Late,” and the authors directly address the myth that uninsured Americans can get the health care they need.

“…working-age Americans without health insurance are more likely to receive too little medical care and receive it too late; be sicker and die sooner; and receive poorer care when they are in the hospital, even for acute situations like a motor vehicle crash,” the report concludes.

Among the IOM’s conclusions:

  • Uninsured adults are less likely than adults with any kind of health coverage to receive preventive and screening services and to receive them on a timely basis. Health insurance that provides coverage of preventive and screening services is likely to result in greater and more appropriate use of these services.
  • Uninsured cancer patients generally are in poorer health and are more likely to die prematurely than persons with insurance, largely because of delayed diagnosis. This finding is supported by population-based studies of persons with breast, cervical, colorectal, and prostate cancer and melanoma.
  • Uninsured adults with diabetes are less likely to receive recommended services. Lacking health insurance for longer periods increases the risk of inadequate care for this condition and can lead to uncontrolled blood sugar levels, which, over time, put diabetics at risk for additional chronic disease and disability.
  • Uninsured adults with hypertension or high blood cholesterol have diminished access to care, are less likely to be screened, are less likely to take prescription medication if diagnosed, and experience worse health outcomes.
  • Uninsured patients with end-stage renal disease begin dialysis with more severe disease than do those who had insurance before beginning dialysis.
  • Uninsured adults with HIV infection are less likely to receive highly effective medications that have been shown to improve survival and die sooner than those with coverage.
  • ]Uninsured patients who are hospitalized for a range of conditions are more likely to die in the hospital, to receive fewer services when admitted, and to experience substandard care and resultant injury than are insured patients.
  • Uninsured persons with trauma are less likely to be admitted to the hospital, more likely to receive fewer services when admitted, and are more likely to die than are insured trauma victims.
  • Uninsured patients with acute cardiovascular disease are less likely to be admitted to a hospital that performs angiography or revascularization procedures, are less likely to receive these diagnostic and treatment procedures, and are more likely to die in the short term.

 

In 2009, the IOM updated their 2002 study in a report entitled “America’s Uninsured Crisis: Consequences for Health and Health Care.” One of the conclusions in the report was that the evidence of the link between mortality and lack of health care insurance has grown much stronger in recent years:

“…the body of evidence on the effects of uninsurance on adults’ health has strengthened considerably since 2002. Numerous studies have addressed some of the methodological shortcomings of past research….17 observational and 13 quasi-experimental rigorous analyses have reported significant findings related to health insurance and adults’ health. The quality and consistency of the recent research findings is striking. As would be expected, health insurance is clearly most beneficial for adults who need medical attention, particularly for adults with common chronic conditions or acute conditions for which effective treatments are available. Furthermore, national studies assessing the effects of near-universal Medicare coverage after age 65 suggest that uninsured near-elderly adults who are acutely or chronically ill substantially benefit from gaining health insurance coverage.”

Further, the report details recent findings showing that even among children, lack of health insurance is independently associated with health outcomes:

“There are 13 recent studies on the health effects of health insurance coverage for children, including 5 studies that used quasi-experimental methods. These studies suggest that health insurance is beneficial for children in several ways, resulting in more timely diagnosis of serious health conditions, fewer avoidable hospitalizations, better asthma outcomes, and fewer missed school days.”

Other studies confirm the IOM’s conclusion that being uninsured is a significant risk factor for morbidity and mortality.

For example, in one study, researchers examined the outcomes of 2,157 hospital admissions for women with spinal metastases from breast cancer. After accounting for the effects of a long list of other variables, the investigators found that women operated on for spinal metastases from breast cancer had worse outcomes and had a higher risk of death if they were uninsured than if they had coverage.

The list of conditions and procedures for which being uninsured is associated with poorer outcomes and higher mortality is shockingly long, so I’ll just name a few: cardiac valve surgery, surgery for colorectal cancer, breast cancer treatment and outcomes, trauma mortality (including among children), and abdominal aortic aneurysms. Further, analyses of data from patients who were uninsured but then reached the age of eligibility for Medicare indicate that “acquisition of Medicare coverage was associated with improved trends in self-reported health for previously uninsured adults, particularly those with cardiovascular disease or diabetes.”

So to sum things up, a very large and robust body of evidence shows that people do, in fact, die because of lack of health insurance.

Conclusions

In an editorial accompanying today’s study in the Annals of Internal Medicine, Dr. Austin Frakt sums up the evidence — and the controversy — over the consequences of being uninsured. Commenting on the findings from the study published today, Dr. Frakt concludes, “This most recent analysis of the Massachusetts health insurance expansion complements a large body of evidence suggesting that insurance is good for health. The likely pathway, also explored in the study, is clear: Coverage expansion is associated with improvements in measures of access to care, such as cost-related delay, usual source of care, and receipt of preventive services.”

He doesn’t stop there. Citing the erroneous argument that lack of health insurance is not associated with mortality, Dr. Frakt writes, “Such claims that health insurance is not good for health have fueled political opposition to the ACA’s subsidized coverage expansion, including nearly half of states opting out of Medicaid expansion. These claims are incorrect.”

But it’s the final few sentences in Dr. Frakt’s editorial that really drive the point home:

Although some health care does not substantially improve health, much of it does. Thus, the conclusion that coverage expansion leads to health benefits by facilitating access is eminently reasonable. What is unreasonable and, in my view, unconscionable is to leverage a selective reading of the evidence on the benefits of health insurance in an argument to deny assistance to Americans who cannot afford to purchase basic coverage.

And with that, I’ll consider this case closed.

 

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