Health Insurance Coverage and Health — What the Recent Evidence Tells Us

Health Insurance Coverage and Health — What the Recent Evidence Tells Us

Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., M.P.H.,

and Katherine Baicker, Ph.D.

https://www.nejm.org/doi/pdf/10.1056/NEJMsb1706645

The national debate over the Affordable Care Act (ACA) has involved substantial discussion about what effects — if any — insurance coverage has on health and mortality. The prospect that the law’s replacement might lead to millions of Americans losing coverage has brought this empirical question into sharp focus. For instance, politicians have recently argued that the number of people with health insurance is not a useful policy metric1and that no one dies from a lack of access to health care. However, assessing the impact of insurance coverage on health is complex: health effects may take a long time to appear, can vary according to insurance benefit design, and are often clouded by confounding factors, since insurance changes usually correlate with other circumstances that also affect health care use and outcomes.

Financial Protection and the Role of Insurance

it is worth recognizing the role of insurance as a tool for managing financial risk. There is abundant evidence that There is abundant evidence that having health insurance improves financial security.

First, policymakers may value publicly subsidized health insurance as an important part of the social safety net that broadly redistributes resources to lower-income populations.

Second, policymakers may view health insurance as a tool for achieving the specific policy priority of improved medical care and public health. Evaluating the impact of insurance coverage on health outcomes — and whether these benefits justify the costs of expanding coverage — is our focus [Scroll down for three.vM]

Access to Care and Utilization

For coverage to improve health, insurance must improve people’s care, not just change how it’s paid for. Several observational studies have found that the ACA’s coverage expansion was associated with higher rates of having a usual source of care and being able to afford needed care,factors typically associated with better health outcomes.

Stronger experimental and quasi-experimental evidence shows that coverage expansions similarly lead to greater access to primary care, more ambulatory care visits,8 increased use of prescription medications, and better medication adherence.

It also found an increased rate of diagnosis, a borderline-significant increase in the rate of treatment with antidepressant medication, and a 30% relative reduction in rates of depressive symptoms.

Though not all cancer results in chronic illness, most cancer diagnoses necessitate a period of ongoing care, and approximately 8 million U.S. adults under age 70 are currently living with cancer. Beyond increases in cancer screening, health insurance may also facilitate more timely or effective cancer care.

Studies do show that for persons reporting any chronic condition, gaining  coverage increases access to regular care for those conditions.19,30 Overall, the picture for managing chronic physical conditions is thus not straight forward, with coverage effects potentially varying among diseases, populations, and delivery systems.

Well-Being and Self-Reported Health

Although the evidence on outcomes for some conditions varies, evidence from multiple studies indicates that coverage substantially improves patients’ perceptions of their health.

Does self-reported health even matter?

 It squarely fits within the World Health Organization’s definition of health as “a state of complete physical, mental, and social well-being,” and improved subjective well-being (i.e., feeling better) is also a primary goal for much of the medical care delivered by health care professionals. In addition, self- reported health is a validated measure of the risk of death. People who describe their health as poor have mortality rates 2 to 10 times as high as those who report being in the healthiest category.

Mortality:

“Does coverage save lives?”

 Beginning with the Institute of Medicine’s 2002 report Care without Coverage, some analyses have suggested that lack of insurance causes tens of thousands of deaths each year in the United States.

More recently, several studies have been conducted with stronger research designs better suited to answering this question. One study compared three states implementing large Medicaid expansions in the early 2000s to neighboring states that didn’t expand Medicaid, finding a significant 6% decrease in mortality over 5 years of follow-up.

A subsequent analysis showed the largest decreases were for deaths from “health-care–amenable” conditions such as heart disease, infections, and cancer, which are more plausibly affected by access to  medical care. [Insert CDC Preventable deaths data here. VM]

It may take years for important effects of insurance coverage — such as increased use of primary and preventive care, or treatment for life threatening conditions such as cancer, HIV–AIDS, or liver or kidney disease — to manifest in reduced mortality, given that mortality changes in the other studies increased over time.

Third, the effects on self-reported health — so clearly seen in the Oregon study and other research — are themselves predictive of reduced mortality over a 5- to 10-year period.

Studies suggest that a 25% reduction in self-reported poor health could plausibly cut mortality rates in half (or further) for the sickest members of society, who have who have disproportionately high rates of death.

 Finally, the links among mental health, financial stress, and physical health are numerous, 45 suggesting additional pathways for coverage to produce long-term health effects

Different Types of Coverage

One head-to-head quasi-experimental study of Medicaid versus private insurance, based on Arkansas’s decision to use ACA dollars to buy private coverage for low-income adults, found minimal differences. Overall, the evidence indicates that having health insurance is quite beneficial, but from patients’ perspectives it does not seem to matter much whether it is public or private.

Finally, though it is outside the focus of our discussion, there is also quasi-experimental evidence that Medicare improves self-reported health48 and reduces in-hospital mortality among the elderly,49 though a study of older data from Medicare’s 1965 implementation did not find a survival benefit.

 Implications and Conclusions

One question experts are commonly asked is how the ACA — or its repeal — will affect health and mortality. The body of evidence summarized here indicates that coverage expansions significantly increase patients’ access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery.

 These increases appear to produce significant, multifaceted, and nuanced benefits to health. Such modest but cumulative changes — which one of us has called “the heroism of incremental care” — may not occur for everyone and may not happen quickly.

But the evidence suggests that they do occur, and that some of these  changes will ultimately help tens of thousands of people live longer lives.

Conversely, the data suggest that policies that reduce coverage will produce significant harms to health, particularly among people with lower incomes and chronic conditions.

The many benefits of coverage, though, come at a real cost.The many benefits of coverage, though, come at a real cost. Given the increases in most types of utilization, expanding coverage leads to an increase in societal resources devoted to health care.

There are key policy questions about how to control costs, how much redistribution across socioeconomic groups is optimal, and how trade-offs among federal, state, local, and private spending should be managed. In none of these scenarios, however, is there evidence that covering more people in the United States will ultimately save society money.

Are the benefits of publicly subsidized coverage worth the cost?

An analysis of mortality changes after Medicaid expansion suggests that expanding Medicaid saves lives at a societal cost of $327,000 to $867,000 per life saved.29 By comparison, other public policies that reduce mortality have been found to average $7.6 million per life saved, suggesting that expanding health insurance is a more cost-effective investment than many others we currently make in areas such as workplace safety and environmental protections.

Factoring in enhanced well-being, mental health, and other outcomes would only further improve the cost–benefit ratio

But ultimately, policymakers and other stakeholders must decide how much they value these improvements in health, relative to other uses of public resources — from spending them on education and other social services to reducing taxes.

There remain many unanswered questions about U.S. health insurance policy, including how to best structure coverage to maximize health and value and how much public spending we want to devote to subsidizing coverage for people who cannot afford it.

 But whether enrollees benefit from that coverage is not one of the unanswered questions.

 Insurance coverage increases access to care and improves a wide range of health outcomes. Arguing that health insurance coverage doesn’t improve health is simply inconsistent with the evidence.

  “There will be deaths”: Atul Gawande on the GOP plan to replace Obamacare

Gawande just reviewed the research on what taking health insurance away means for Americans.

Updated by Julia Belluz@juliaoftoronto [email protected] Jun 23, 2017, 9:23am EDT

As a doctor, I find this unconscionable,” Gawande says of taking health insurance away from people

As the GOP inches closer to repealing and replacing Obamacare, there’s no shortage of claims flying around about the impact giving people health insurance — or taking it away — has on American lives.

Researcher, policy wonk, and New Yorker writer Atul Gawande had heard them all: Medicaid doesn’t work, driving down coverage rates will result in more deaths, insurance coverage doesn’t actually improve health or mortality, and on and on.

So he wanted to comb through the research himself to see what studies on the health effects of health insurance show. Together with resarchers Benjamin Sommers and Katherine Baicker — who are two of the leading experts on this subject — Gawande just put out a review of that literature.

Their analysis was published Wednesday in the New England Journal of Medicine, on the eve of the long-awaited release of the Senate health reform bill, the Better Care Reconciliation Act.

The trio’s conclusions are pretty unequivocal.

“The bottom line,” Gawande told Vox, “is that if you’re passing a bill that cuts $1.2 trillion in taxes that have paid for health care coverage, there’s almost no way that does not end up terminating insurance for large numbers of people.”

He continued: “If you are doing that, then there’s clear evidence that you will be harming people. You will be hurting their access to care. You will be harming their health — their physical health and mental health. There will be deaths.

As a doctor, I find this unconscionable.”

For every 300 to 800 people who get insurance, about one life is saved per year, they found. The cost to society is somewhere between $300,000 and $800,000 per life saved.

“Other policies that save lives — for example, health worker safety protections and environmental regulations — cost closer to $7.6 million per life saved,” he said. That means health insurance is a pretty good deal.

It also means the debate about the repeal and replacement of Obamacare, and whatever health law, if any, comes next, is really a debate about what we value as a society and whether we consider these costs worthwhile.

For a summary of their findings, check out Gawande’s tweetstorm yesterday:

As a doctor, I find this unconscionable.”

For a summary of their findings, check out Gawande’s tweetstorm yesterday:

1.        @NEJM People are more likely to have a usual source of medical care and to be able to afford needed medical care
2.        @NEJM Fewer medical bills are sent to collections. Fewer bankruptcies. Virtual elimination of catastrophic out-of-pocket expenses
3.        @NEJM People have greater access to primary and preventive care, chronic illness treatment, and medications.
4.        @NEJM 15-30% more people get screened for high cholesterol and cancer.
5.        @NEJM Nearly twice as many patients take necessary diabetes medication.
6.        @NEJM Depression symptoms (leading cause of disability in US) are reduced by 30%, and more people are diagnosed successfully.
7.        @NEJM More low-income patients get necessary surgery for colon cancer before it's too late
8.        @NEJM Result: 25% more people report being in good or excellent overall health.
9.        @NEJM Longest study: Medicaid cut mortality 6% over 5 yrs. Biggest gains came from healthcare-amenable dx like heart disease, cancer, infection
10. @NEJM The longer people have coverage, the greater the mortality reduction.
11. @NEJM Overall, for every ~300 to 800 adults who get coverage, rigorous studies suggest we save one life per year.
12. @NEJM Increasing coverage through Medicaid has been at least as effective as doing so through private insurance
13. @NEJM In sum: Coverage has made people healthier and helped 10s of thousands per year live longer, healthier lives.
14. @NEJM Weakening coverage will increase medical debts, untreated sickness, and deaths.