Read: Why states want certain Americans to work for Medicaid

If Medicaid does not make people healthier, it cannot save their lives either: This became a common argument in conservative circles, one wielded again and again against the ACA. “No one wants anybody to die,” Raul Labrador, an Idaho Republican and a former member of the Freedom Caucus, argued, for instance, pushing back on a constituent criticizing the GOP’s health plans. “That line is so indefensible. Nobody dies because they don’t have access to health care.”

But the Oregon study looked at health outcomes only over a short period of time, and at non-elderly adults who tend to have a pretty low death rate anyway. Other studies indicate that gaining coverage does have health and mortality effects. This new study is one of them. It looked at ample data on a targeted population—people nearing Medicare age, who live in poor households or do not have a high-school diploma—who tend to have poor health and for whom good insurance coverage might make a major difference. It does, the study found. Death rates dropped in the states that expanded Medicaid, saving 19,200 lives over four years. Had all 50 states expanded the program, 15,600 further deaths would have been averted.

These are the very real stakes of the health-care debate. The ACA saves lives. Universal insurance would save more. Although Republicans don’t see it this way, their health plans, which would result in fewer insured people, would also result in thousands of avoidable deaths each year.

In March, the Trump administration asked the courts to strike down the entire ACA, something that would not just dismantle the Medicaid expansion but also eliminate the insurance exchanges, stop requiring insurers to let children stay on their parents’ plans until the age of 26, strip away protections for patients with preexisting conditions, allow for insurers to reinstate lifetime coverage limits, and so on.

Nicholas Bagley: Rise of the know-nothing judge

As this new study suggests, the Supreme Court may have altered the country’s health and mortality rates, too. Back in 2012, when the Court upheld the ACA’s individual mandate but allowed states to opt out of the Medicaid expansion, Court watchers expressed shock. New reporting from CNN’s Joan Biskupic suggests that the decision came about as part of a political negotiation among the justices: The mandatory Medicaid expansion—never one of the more legally controversial parts of Obamacare—was the cost of Roberts upholding the central tenets of the law.

For the poor, older adults of the red states that chose not to expand Medicaid, that negotiation may have been a lethal one.

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