Estimating the Affordable Care Act's Impact on Health
With the Supreme Court ruling in favor of the government in King v. Burwell, opinion polls suggest that some Americans are taking a fresh look at the Affordable Care Act (ACA), and reassessing its merits. A key question for them—and one that is rarely discussed—is how the ACA will improve the health of those who gain insurance coverage.
A recent study published by the Centers for Disease Control and Prevention attempts to quantify this benefit for individuals with hypertension. The authors project that, thanks to the ACA, increased use of antihypertensive medication will lead to 111,000 fewer cases of coronary heart disease, 63,000 fewer strokes, and 95,000 fewer deaths by 2050. And this estimate may understate the health gains, since their model assumes the ACA expands coverage to 13.9 million adults—a modest figure given that recent surveys estimate between 12 million and 17 million adults have already gained coverage.
Regardless, these are eye-catching numbers. And they tell only a piece of the story, as hypertension treatment is just one of the innumerable pathways through which health insurance can improve health. Other pathways have been documented by a substantial body of literature, summarized in a 2009 report from the Institute of Medicine (now the National Academy of Medicine). Some other examples of the benefits of health insurance include:
- Being less likely to have cancer diagnosed at an advanced stage.
- Among people with diabetes, achieving better glycemic control.
- Having a lower risk of death when admitted to the hospital with a severe acute illness.
- Receiving significantly more care and being less likely to die after a car accident.
Of course, along with these health benefits, insurance also provides financial protection against unaffordable health care costs.
Some may caution against overemphasizing the link between health insurance and health. After all, the Oregon Medicaid study—which employed a uniquely powerful methodology based on randomized assignment of coverage—did not find that gaining insurance led to statistically significant improvements on several clinical measures of physical health.
However, the Oregon findings are best seen as complementing the literature on health benefits and coverage, rather than running counter to that literature. Because the study had relatively small sample sizes of patients with health problems, quite large clinical improvements would have been needed to meet the threshold of statistical significance. And the study did find statistically significant improvements in self-reported health and a 30 percent reduction in the rate of observed depression. Depression can lead to or exacerbate physical health problems like heart disease, diabetes, and stroke, particularly when it goes untreated. The Oregon study also was limited to only 17 months, which is a short time frame for measuring an effect that likely compounds over time.
Another important study on the subject compared trends in health status in Massachusetts to other areas of the country after the state’s 2006 health insurance expansion.
The authors found that the Massachusetts reform was associated with a significant reduction in mortality, equivalent to about 1 death prevented for every 830 adults who gained insurance. To put that in perspective, if the Massachusetts results hold for the ACA, it could already be saving tens of thousands of Americans’ lives each year.
Individually, none of the studies is perfect, but together they point to the same conclusion: health insurance leads to healthier, longer lives. If health insurance were a drug, these potent effects on health would create a huge clamor for the FDA to approve it. As the political sparring over the ACA’s implementation continues in the coming months and years, we should keep it mind the proven health benefits of health insurance.