Source: Alan Cleaver (Flickr / Creative Commons)
While it has been estimated that 45,000 Americans perish unnecessarily each year due to lack of health insurance, there has been some mixed evidence about the mortality benefit of expanding coverage, particularly Medicaid.
A study in Oregon showed no clear mortality benefit to extending Medicaid to a randomized group of uninsured adults, and another study from the Beaver State showed no significant improvement in physical health measures associated with Medicaid coverage even with significantly increased utilization and health care costs.
However, a recent study of the Massachusetts health care reform published in Annals of Internal Medicine provides strong evidence to support the premise that expansions in insurance coverage are associated with a significant decrease in all-cause mortality, with reductions concentrated among deaths amenable to health care. This study, authored by some of the same researchers responsible for the Oregon studies, suggests that there is, in fact, a clear mortality benefit associated with insuring the uninsured.
In this study, researchers compared annual county-level all-cause mortality as well as deaths amendable to health care, self-reported health, and access-to-care measures. Deaths amendable to health care were those attributed to causes that are more likely to be successfully prevented or treated with timely access to care, like heart disease, stroke, cancer, and infection.
By comparing pre- and post-mortality changes in Massachusetts with similar populations in states not implementing reform, the study found an absolute decrease of 8.2 deaths per 100,000 adults due to all-cause mortality. The was estimated to be 830 adults gaining insurance to prevent 1 death per year.
Health care reform in Massachusetts, implemented in 2006, is believed to be the precursor to the , which was signed into law in 2010. contained many key provisions that were replicated in the ACAincluding the individual mandate and expansion in the availability of affordable private coverage through an exchange (Massachusetts Health Connector). Thus, this study provides encouraging evidence to support the premise that health insurance expansion translates to improved health outcomes.
However, Massachusetts is an atypical state: compared to national averages, Massachusetts has higher average incomes, higher baseline rates of insurance, and the highest per capita concentration of physicians in the country. Its more challenging to envision how such gains will be realized in states like Mississippi, Idaho, and Nevada that have less than half the amount of physicians as Massachusetts.
Of course, physician distribution is one of several factors affecting access, but at a minimum, it seems obligatory to reiterate the need for more careful, data-driven, centralized health professional workforce planning.
by Elizabeth Wiley, MD, JD, MPH