The Affordable Care Act might not bend the cost curve or improve the quality of health care, but it will save thousands of lives, as millions of uninsured persons receive the health care they need.
At least that’s the conventional wisdom.
But while observers assume that ACA will improve the health of the uninsured, the link between health insurance and health is not as clear as one may think. Partly because other factors have a bigger impact on health than does health care and partly because the uninsured can rely on the health care safety net, ACA’s impact on the health of the previously uninsured may be less than expected.
To be sure, the insured are healthier than the uninsured. According to one study, the uninsured have a mortality rate 40% higher than that of the insured. However, there are other differences between the insured and the uninsured besides their insurance status, including education, wealth, and other measures of socioeconomic status.
How much does health insurance improve the health of the uninsured? The empirical literature sends a mixed message. On one hand is an important Medicaid study. Researchers compared three states that had expanded their Medicaid programs to include childless adults with neighboring states that were similar demographically but had not undertaken similar expansions of their Medicaid programs.
In the aggregate, the states with the expansions saw significant reductions in mortality rates compared to the neighboring states.
On the other hand is another important Medicaid study. After Oregon added a limited number of slots to its Medicaid program and assigned the new slots by lottery, it effectively created a randomized controlled study of the benefits of Medicaid coverage. When researchers analyzed data from the first two years of the expansion, they found that the coverage resulted in greater utilization of the health care system.
However, coverage did not lead to a reduction in levels of hypertension, high cholesterol or diabetes.
Also, in a nationwide study of people age 50-61, researchers looked at the study subjects’ access to health care and their health outcomes for the next 18 years. As expected, insured individuals used more health care resources than did uninsured people.
However, there was no evidence that being insured lowered the risk of death 12-14 years into the study, and only mild evidence of a mortality benefit at 16-18 years.
All of this is not to say that health care does not matter. Rather, it is not clear how much more ACA will do for the health of the previously uninsured than did the pre-ACA safety net. The safety net is porous, but it provides important benefits to the uninsured. In addition, ACA’s impact will be limited because it put most of its money on treatment, and that was not a wise bet.
It has long been clear that public health interventions do more to promote health than do treatments of disease. It also may be true that health care coverage is a necessary but not sufficient factor in improving a person’s health. The uninsured face many barriers to receiving good health care, and they often may need other kinds of assistance to ensure that they realize the full benefits of health care coverage.
In the end, the benefits of ACA may lie more in their contribution to economic health than physical health. Support for ACA was driven in large part by concerns about the extent to which health care costs were overwhelming family budgets and forcing Americans into bankruptcy.
ACA will greatly reduce the financial burden from health care needs, and this is very important.
David Orentlicher, MD, JD is Samuel R. Rosen Professor at Indiana University’s Robert H . McKinney School of law and adjunct professor of medicine at Indiana University School of Medicine. This piece originally appeared on his personal blog, orentlicher.tumblr.com.
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