Health Insurance and Mortality, Part 1

In 2006, Massachusetts implemented the country’s first comprehensive health care reform (“Romneycare”). It made health insurance mandatory for nearly all citizens, expanded Medicaid to cover people earning up to 150% of the federal poverty level (FPL), and provided health insurance subsidies for people with incomes up to 300% of FPL. It became the structural model for the Affordable Care Act (ACA). A previous study showed that Massachusetts residents reported themselves to be in better health following the implementation of Romneycare. A new study out this week shows that health care reform significantly reduced the mortality rate in Massachusetts compared to nearby states. This is the bottom line in health care research. It’s good news not only for the ACA, but for single payer advocates as well, since single payer would further expand the number of people covered by health insurance and would presumably reduce the red tape and out-of-pocket costs that keep some people from using health care.

The study, by Drs. Ben Sommers, Sharon Long, and Katherine Baicker, is a quasi-experimental design. It lacks an important feature of true experiments—random assignmnent of participants to conditions—but attempts to compensate for this by using a matched comparison group that controls for most plausible alternative explanations. In this case, the experimental group was the citizens of Massachusetts. Each county in Massachusetts was matched with a comparison county drawn from a nearby state. The counties were matched for age distribution, race and ethnicity, poverty, income, unemployment, lack of health insurance, and their existing mortality rate. The authors compared the mortality rates of adults under 65 from 2001-2005 (prereform) to 2007-2010 (postreform). Here are the results.
  • Mortality in Massachusetts declined 2.9% relative to the comparison group. This is equivalent to 8.2 deaths per 100,000 people, or one death prevented for every 830 people who obtain health insurance. The New York Times calculates that a national 2.9% decline in mortality among adults under 65 would translate to about 17,000 lives saved per year. Harold Pollack claims that the number is as high as 24,000 per year.
  • Mortality “amenable to health care,” i.e., from causes such as cancer, heart disease and diabetes, declined 4.5% relative to the control group. Mortality from causes not amenable to health care was unchanged. See the chart below.
  • Mortality among people over 65 was unaffected. This is to be expected, since senior citizens already had Medicare.
  • Reductions in the mortality rate were greatest among counties with the lowest incomes and the lowest rates of insurance coverage prior to reform.
  • As you would expect, the study also found significant increases in insurance coverage, access to medical care, and self-reported health in Massachusetts compared to the comparison group.
As health care expert Austin Frakt has noted, this study constitutes the strongest evidence yet that having health insurance can save your life. Nevertheless, the study is not without its critics. I will look at some of those criticisms in Part 2 of this post.
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