In The Arena Death on the Installment Plan Now we know: Rejecting the Medicaid expansion could kill nearly 6,000 people each year.

Harold Pollack teaches social service administration at the University of Chicago. A fellow of the Century Foundation, he’s a regular contributor to the Washington Post’s Wonkblog section and to healthinsurance.org.

Like many other liberal health-policy wonks, I’ve written a lot about the value of health reform in improving access to preventive care, protecting people against crippling medical debt and improving people’s physical and mental health.

I haven’t written much about how better access to health care can actually save lives. The argument for the Affordable Care Act, President Obama’s signature health-care-law, doesn’t ride on this. Moreover, the connection between health insurance and mortality is really hard to pin down, even if insurance truly has strong protective effects. The uninsured in America are mainly non-elderly adults. Deaths are really rare in this population, on the order of 0.4 percent per year. according to an Urban Institute study. Real-world randomized clinical trials—even those with thousands of patients—are just too small and too brief to reliably determine how much we might reduce mortality by extending coverage to the uninsured.


On Monday, though, a beautiful study was published in Annals of Internal Medicine that provides some of the best data we have connecting health coverage to saved lives. It’s changed my thinking, too. I’m more confident than I was last week that the ACA will save many thousands of lives every year.

Ironically, the study examined the impact of the bipartisan insurance expansion enacted in Massachusetts in 2006—a.k.a. “RomneyCare,” which provided the basic model for the ACA. Three of the best researchers in the business—Benjamin Sommers, Sharon Long and Katherine Baicker examined a decade’s worth of mortality data in Massachusetts counties, comparing trends to those found in carefully chosen comparison counties in other states. This wasn’t a randomized trial, but it was the next best thing, tracking the experiences of hundreds of thousands of people for years before and after the enactment of Massachusetts’ reforms.

Here’s their bottom-line result: Insurance coverage reduced mortality rates by about 30 percent. For every 830 people newly insured, Massachusetts prevented one death per year.

The sheer craftsmanship of this study makes it a pleasure to read (at least, if you’re a health wonk like me). It includes several smart checks to rule out potential biases. For example, Sommers, Long and Baicker show that mortality rates among elderly Massachusetts residents were basically unaffected by the 2006 reforms—which makes sense because almost everyone in this group was already insured through Medicare. The authors also demonstrate especially strong mortality reductions for conditions that are actually amenable to medical intervention, such as strokes.

Do these results generalize to the national expansion of coverage under the Affordable Care Act? Nobody really knows. Massachusetts has done a better and more enthusiastic job implementing RomneyCare than many states (and the federal government) have done thus far with ACA.

On the other hand, Massachusetts experienced the strongest survival benefits in low-income areas that contain many uninsured people. These counties look more like those in less-prosperous states most affected by health reform. Massachusetts began its reform as a prosperous liberal state with effective public health polices and a strong infrastructure of safety-net care. Other states are starting with a much less favorable baseline, and thus hold more dramatic possibilities for improvement. A state like Kentucky, which just provided coverage for the first time to hundreds of thousands of very poor people, might well see larger effects.

One thing is for sure. If anything close to these results apply, the ACA is saving many lives every year. The new law is projected to cover more than 20 million adults who would otherwise go uninsured. The Massachusetts estimates imply that the ACA will prevent something in the neighborhood of 24,096 deaths every year (simply: 20 million divided by 830). That’s more than twice the number of Americans killed in gun homicides. It’s considerably more than the number of Americans who die from HIV/AIDS.

The Cato Institute’s Michael Cannon rightly notes that these mortality reductions won’t come cheap. My own faux-precise back-of-the-envelope calculation suggests that the cost per averted death is about $3.3 million. That seems like a lot of money—and it is. Yet it actually compares favorably in cost-effectiveness with other widely accepted medical, public health, product safety and workplace interventions. The U.S. Department of Transportation uses a baseline threshold of $9.1 million (and a range of $5.2 million to $12.9 million) in policy analyses to evaluate measures to prevent automobile fatalities. And of course this $3.3 million only captures the impact of health reform on reducing mortality rates. It doesn’t count so many other important health, financial and personal benefits of health coverage, from regular preventative care to peace of mind.

For many conservative politicians, these benefits are not enough. In NFIB v. Sebelius, the Supreme Court gave states the option of rejecting the ACA’s Medicaid expansion—the main lever for boosting coverage for Americans with incomes below the federal poverty line. Many Republican governors and GOP-dominated state legislatures have done precisely this.

As a matter of fiscal policy, this makes little sense. The federal government would initially cover 100 percent of the costs. Its share will gradually drop to 90 percent over the coming years. Over the next decade, the federal government will cover more than 95 percent of the Medicaid expansion’s total cost. Edwin Park of the Center on Budget and Policy Priorities notes that the ACA raises state expenditures on Medicaid and the Children’s Health Insurance Program (CHIP) by only 1.6 percent, when compared with what expenditures would have been in the absence of health reform.

Even the above figures overstate states’ true fiscal burden, since these federal dollars would cover many services such as mental health care, public hospital services and services to the correctional population that would otherwise be supported by states and localities. Medicaid expansion is a significant economic stimulus to the states that have adopted it. Even in deeply conservative states such as Texas, the expansion is strongly supported by the medical community, hospitals, cities and localities and other key constituencies.

Texas and other huge states like Florida are leaving tens of billions of dollars on the table. When asked to give an accounting of themselves, officials offer flimsy justifications to evade two obvious realities: First, Republican politicians do not want to embrace the centerpiece domestic policy achievement of the Obama presidency. Second, many of these same politicians display conspicuously tepid concern for the wellbeing of the expansion’s most obvious beneficiaries: poor, nonwhite, politically marginal residents of their own states.

We’ve run this tape before, which gives reason to hope that this issue will eventually be worked out. Some of the very same states bitterly resisted Medicare and Medicaid 50 years ago. It took until the early 1970s for southern states to embrace Medicaid. Once President Obama leaves office, it will become politically easier for many Republican politicians to find a dignified path to follow more moderate figures such as Arizona’s Jan Brewer and Ohio’s John Kasich, who have already embrace the expansion. In states such as Florida and Georgia, the logjam might also come unstuck by some local crisis, such as the collapse of a major public hospital system deprived of the expansion’s additional Medicaid revenue.

Delay still brings enormous human costs. Nearly 5 million low-income Americans are income-eligible for Medicaid under the ACA, yet live in states that now reject the Medicaid expansion. Within this rather small but critical low-income population, that same one-per-830 estimate implies that almost 5,800 people will die every year as a result of being left uninsured. That’s only an estimate. It may overestimate—or underestimate—the true human consequences. In my view, there’s no escaping the fact that partisan opposition to the ACA is costing thousands of actual human lives every year.

Jon Gruber—an economist at the Massachusetts Institute of Technology and a key designer of both the ACA and RomneyCare— bluntly summarized the situation: “They are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.”

That is not a worthy legacy; nor is it a promising path to political success in a changing America.