[Vision2020] RomneyCare Saves 17,000 (mostly poor) Lives per Year

Tue May 6 09:10:33 PDT 2014

BOSTON  (New York Times, May 5, 2014)— The death rate in Massachusetts
dropped significantly after it adopted mandatory health care coverage in
2006, a study released Monday found, offering evidence that the country’s
first experiment with universal coverage — and the model for crucial parts
of President Obama’s health care law — has saved lives, health economists
say.

The study tallied deaths in Massachusetts from 2001 to 2010 and found that
the mortality rate — the number of deaths per 100,000 people — fell by
about 3 percent in the four years after the law went into effect. The
decline was steepest in counties with the highest proportions of poor and
previously uninsured people. In contrast, the mortality rate in a control
group of counties similar to Massachusetts in other states was largely
unchanged.

A national 3 percent decline in mortality among adults under 65 would mean
about 17,000 fewer deaths a year.

“It’s big,” said Samuel Preston, a demographer at the University of
Pennsylvania and an authority on life expectancy. Professor Preston, who
was not involved in the study, called the study “careful and thoughtful,”
and said it added to a growing body of evidence that people with health
insurance could reap the ultimate benefit — longer life.

*A Drop in Mortality *

The death rate in Massachusetts declined after the state’s health care law
was adopted in 2006, while the rate in similar counties in other states
stayed flat.

Experts said the study, which was published online Monday in the Annals of
Internal Medicine <http://annals.org/article.aspx?articleid=1867050>, will
not settle the long-debated question of whether being insured prolongs
life, but it provides the most credible evidence yet that it might. Still,
health improvements can take years to surface in mortality data, and some
researchers were skeptical of the magnitude and suddenness of the decline.

“Health care is a much more involved process — you don’t just sign up and
suddenly get well,” said Joseph Antos, a health economist at the
conservative American Enterprise Institute.

Massachusetts is whiter and more affluent than most states, and has more
doctors per capita and fewer uninsured people. But researchers said that
the state’s health insurance law nevertheless amounted to the best natural
experiment the country has had for testing the effects of a major insurance
expansion on a large population.

Another study, in Oregon, found that Medicaid, the insurance program for
the poor, improved mental health and financial security, but not physical
health, and the study was too small to gauge mortality effects.

“This is an important piece of the puzzle,” Katherine Baicker, a professor
of health economics at the Harvard School of Public Health, who took part
in both studies, said of the Massachusetts one. “Putting the evidence
together paints a very strong picture that expanding insurance
substantially improves the well-being of people who get it.”

In the waiting rooms of the East Boston Neighborhood Health Center,
bustling with a working-class clientele, doctors said much had changed
since the state insurance law passed in 2006. People are less likely to put
off care out of fear of unaffordable bills, and patients with diabetes can
get medication regularly.

Dr. Stelios Maheras, medical director of the emergency department, said
some patients used to ask for prices “like at the supermarket.” He recalled
one patient who was having chest pains but refused an ambulance because he
was afraid of the bill.

“I said, ‘You can’t drive yourself to the hospital — that’s a stress test
all on its own!’” Dr. Maheras said. “The attitude has totally changed,” he
said, adding that his patients now felt less financially vulnerable and
more confident.

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In Suffolk County, which includes Boston, the death rate for adults under
65 dropped by about 7 percent from 2005 to 2010, the study’s authors said.

There have been patchy efforts to improve coverage for the poor in states
like Arizona, Maine and New York, but Massachusetts is the only state to
fully overhaul its health system to cover almost everybody.

But studying the state in isolation was problematic: Was the mortality
decline due to expanded insurance coverage, or other factors such as
improved eating habits or lower smoking rates? The authors identified 513
counties in 46 other states that were most similar to Massachusetts before
reform in demographics and levels of poverty and insurance, then compared
their mortality rates with that of Massachusetts. They found that the rate
declined 2.9 percent in Massachusetts, but remained flat in counties
outside the state.

Dr. Catherine Silva, of the East Boston center, said previously uninsured
patients were now less likely to disrupt treatment. Credit Dominic Chavez
for The New York Times

Researchers also examined death rates for people 65 and over, a population
that had been minimally affected by the insurance overhaul. Mortality
patterns over time in that age group were the same in Massachusetts and in
the control counties.

Dr. Benjamin Sommers, the lead author and a health economist and physician
at the Harvard School of Public Health, cautioned that researchers did not
have individual data on the 270,000 people who had gained insurance in the
state, and could not tell for sure whether it was the expansion that had
driven the mortality decline.

Dr. Sommers said that he spent several hours a week advising the Department
of Health and Human Services, which pays Harvard for his time, but that it
had neither funded nor vetted the study.

Experts said the study was the best attempt yet to isolate the effects of
insurance.

David O. Meltzer, a health economist from the University of Chicago, who
was not involved in the study, said one of the study’s strengths was its
size. It looked at four million people in Massachusetts — the entire
population age 20 to 64 — and compared them with more than 44 million
people in control counties.

“In the hierarchy of evidence, this ranks way above everything we’ve seen
in the past in terms of the effects on mortality,” Professor Meltzer said.

The biggest declines happened for conditions that are more likely to be
deadly if not caught early — for example, infections from complications of
diabetes, heart attacks and cancer.

Dr. Catherine Silva, a primary care physician at the East Boston health
center, said some fatalities might have been prevented by helping people
control their high blood pressure and cholesterol, which can increase the
risk of heart attacks. She recalled a patient who had hypertension, but
dropped out of treatment when she lost insurance, and came back three years
later with breast cancer that proved tricky to treat because she had
uncontrolled high blood pressure and diabetes.

“That conversation about why did you leave me for three years, that doesn’t
happen anymore,” she said.

Researchers have long debated whether having health insurance and better
access to medical care saves lives, but it has been hard to construct a
study to settle the issue. In 2002, the Institute of Medicine estimated
that a lack of health insurance was responsible for 18,000 deaths a year in
the United States. But in 2009, a researcher from the University of
California found that the survival rate of uninsured people resembled that
of insured people.

There will be more evidence, as well, in coming years. The Affordable Care
Act is its own sweeping experiment, as only about half the states expanded
Medicaid.

“It’s very unfortunate for people living in states not expanding Medicaid,”
said Richard Kronick, a health policy official at the Department of Health
and Human Services, “but from the point of view of research, it’s a gold
mine.”

*Correction: May 5, 2014 *

An earlier version of this article misstated where the decline in the death
rate was steepest. It was in counties with the highest proportions of poor
and previously uninsured people, not poor and uninsured people.
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