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Today in Obamacare: an interview with the Harvard researcher who found Medicaid saves lives

Disparities in health care are now more about income inequality than racial inequality.

Demonstrators march and rally to protest against President Donald Trump's and the GOP's race to repeal and replace the Affordable Care Act (aka Obamacare) at Los Angeles, California.
Aydin Palabiyikoglu/Anadolu Agency/Getty Images

When you listen to the political infighting in Washington over Obamacare, it’s easy to forget that human lives hang in the balance if the law is repealed.

That’s why the work of Benjamin Sommers, a health economist and physician based at Harvard University, has been so critical.

Over the past few years, Sommers has amassed some of the best evidence on exactly how health insurance can impact health and mortality in America, with a particular focus on vulnerable populations like Medicaid recipients. His findings are pretty unambiguous: Giving people health coverage saves lives. And taking away health insurance could lead to as many as 24,000 deaths — more than the death tolls from firearm homicides, HIV, and skin cancer in the US each year.

He’s also discovered that at a time of growing income inequality, disparities in health care tend to be even more extreme between the rich and the poor than they are among different racial groups, and that low-income adults in states that expanded Medicaid have more positive experiences with Obamacare than their counterparts in states that didn’t broaden health coverage.

Taken together, Sommers’s research reminds us why repealing or altering the law in a way that limits coverage is a political hot potato. It also shows us exactly how any changes in health insurance will most certainly determine who lives and who dies in America. Here’s more from our conversation with him, edited for length and clarity:

Julia Belluz

One of the best indicators of Obamacare’s dramatic impact on mortality came from your data on how health insurance affects people living with HIV. You found mortality declined by 20 deaths per 100,000 as a result of broadening health insurance coverage — and a stunning 20 percent of that decline came from the reduction in HIV-related mortality. Do you think HIV is different from other diseases in terms of the impact of health insurance? And what can the HIV experience teach us about how to save lives with health coverage?

Benjamin Sommers

HIV was the condition that was hardest to study well in that Medicaid expansion analysis, simply because New York — the largest expansion state in that study — had an HIV prevalence that was far and away higher than any other state in the sample. So it’s more challenging to say definitively that the HIV-related mortality reductions we found were just from insurance. My own take on the findings is that it was a combined effect of new effective therapies for HIV becoming widespread around the same time as this coverage expansion.

For a chronic and expensive condition like HIV, there’s good reason to think that health insurance is even more important than it is for the general population.

But there are also many other conditions that are similarly life-threatening if not managed well that can be controlled with expensive and often high-cost medications.

For diabetes, heart disease, hepatitis C, and some cancers, for instance, it seems equally plausible that health insurance can be a pathway to improved quality and length of life. In the aggregate, that’s just what our studies have shown: Coverage expansions have their largest impact on causes of death from conditions like the ones I just listed, which are potentially most amenable to timely health care, as opposed to, say, car crashes and homicides.

Julia Belluz

What do we know about the people who have been left behind by Obamacare, including those who got the insurance but still feel it didn’t help them? In a forthcoming Millbank Quarterly paper, you document how the ACA didn’t spread health care access and affordability evenly across the US. …

Benjamin Sommers

Large disparities in health care experiences persist among minorities and lower-income Americans, even though the ACA has helped those groups disproportionately. The fact is that health care and health outcomes are worse for these groups for many reasons, and health insurance coverage is only one factor.

So the ACA’s large coverage expansion doesn’t eliminate most of the disparities in our health care system that many, including me, find so troubling.

It’s worth noting in this era of both racially charged politics and growing income inequality that the differences by income far exceed what we observed based on race and ethnicity. This is consistent with some of the emerging studies showing how lower-income whites have really struggled economically and health-wise in recent years, much as lower-income minorities have.

Julia Belluz

One strand of your research focuses on the impact of health insurance on vulnerable populations — for example, your new NEJM paper that documents how low-income Americans perceive the law. What have you found are the best predictors of whether or not someone felt the ACA benefited them?

Helped or hurt by Obamacare from a survey of low-income adults in 2016.
NEJM

Benjamin Sommers

The two strongest predictors were what type of coverage someone had and where they lived. People with Medicaid or marketplace coverage were quite positive in talking about the law — 41 percent said it had helped them, compared to just 12 percent who said it had hurt them, and the remainder said the law had no direct impact.

Meanwhile, those in Kentucky, Arkansas, and Louisiana all reported much higher rates of benefiting from the ACA, while in Texas only 18 percent said the law had helped.

And this makes perfect sense: Low-income adults in Texas really didn’t benefit much from the ACA, because the governor and legislature kept most of them from having an affordable option for health insurance by not expanding Medicaid.

Actually, what I find interesting about the results is how much sense they make: In states that are quite conservative and pretty hostile to President Obama in general, the people we surveyed were quite willing to credit the ACA as having helped them. This has always been such a polarizing law politically, but at least in our survey, the value of gaining coverage itself seemed to win out in how people assessed it.

This is part of the reality that is making the push for repeal a much trickier proposition in Congress than many originally envisioned.

Julia Belluz

If you were health czar for the day, and had the power to reform the ACA based on what you know about health insurance now, what would you fix?

Benjamin Sommers

I’d get as many of the remaining non-expansion states to find a path toward expansion that they can live with, whether it be the Arkansas model, Michigan's approach, or a plain old Medicaid expansion.

Then I’d focus on stabilizing competition and premiums in the marketplaces. I’m not one who thinks the marketplaces are fundamentally broken; I think some regions are in more trouble than others, but none beyond repair.

Reinstating the risk protection features for plans in the marketplace — the risk corridor and reinsurance programs — with full funding would help, and, even more importantly, an all-out enrollment effort that would capitalize on navigators and other assistance programs could improve the risk pool.

Beyond the risk of repeal, the biggest threat to the marketplaces right now is simply how much political uncertainty there is. As long as the administration and congressional leaders keep rattling their sabers about repeal or even just their rhetoric that the marketplaces are doomed, they’re only going to make the issues of plan exits and premiums increases worse.

Julia Belluz

There’s so much uncertainty right now about the future of the law. What worries you most about a potential repeal or replacement plan in terms of public health and mortality in America?

Benjamin Sommers

This is a congressional debate, and truly repealing the law requires legislation. I think [HHS Secretary Tom Price’s] views toward the ACA are pretty clear, but it’s much less obvious that Republicans in Congress will have the votes they need to roll back substantial portions of the law.

We’re already seeing that many moderate Republicans and those from states with large coverage expansions are concerned about the implications of a repeal, and I think that’s appropriate. Our research suggests that when people gain health insurance, whether via Medicaid or private insurance along the lines of the ACA’s marketplaces, they experience significant benefits: better access to care, better chronic disease management, improved well-being and perceived health, and lower risks of death. So any major rollback of the ACA’s coverage gains could leave millions of people without health insurance.

Our study of Massachusetts’s 2006 health reform, the model for the ACA, suggested that one life was saved for every 830 people covered. The Obama White House took that number and said 24,000 lives per year could be saved by the ACA. I can’t tell you that this is the exact right number — it’s a challenging extrapolation — but I think our study makes a strong case that this debate is a matter of life and death for many Americans.

Chart of the day

The uninsured rate remains at a record low, according to brand new data from the CDC [Centers for Disease Control and Prevention]. In the first nine months of 2016, 28.2 million, or less than 9 percent, of adults were uninsured, more than 20 million fewer persons than in 2010.

Percentage of adults ages 18 to 64 who were uninsured at the time of interview, by age group: United States, 2010–September 2016.
CDC

Today’s top three health policy reads

“Red-State Medicaid Expansions — Achilles’ Heel of ACA Repeal?: “Although 19 states have declined to implement the Medicaid expansion, this feature of the law has seen more bipartisan support at the state level than most other aspects of the ACA. More specifically, 13 states won by Donald Trump in the 2016 presidential election have opted into the ACA’s Medicaid expansion since 2014, and 16 expansion states are currently led by Republican governors.” —Benjamin Sommers and Arnold M. Epstein, New England Journal of Medicine

“Will Obamacare Really Go Under the Knife?”: “Though it may appear otherwise in a dawning age of Republican near-monopoly on government, the [Obamacare] argument is today far from over. According to a January Fox News poll, Obama’s signature program now enjoys a 50 percent approval rating. There is no guarantee that Republicans in the Senate will sign onto legislation that risks leaving millions of their constituents suddenly without health care coverage while alienating key donors — drug makers, insurance companies and doctor associations — who helped shape and support the law Trump now seeks to replace. ‘The joke around Washington,’ the former Democratic congressman Jim McDermott told me, ‘is that the Republicans are going to repeal Obamacare — and they’ll replace it with the Affordable Care Act.’” —Robert Draper, New York Times

“For so many Americans, Obamacare offered career freedom. A repeal could take that away.” “I spend a lot of time talking to Obamacare enrollees like Hoover: people who struck out on their own — left a job, started a business, went back to school — after Obamacare. They felt empowered to do this because in the reformed individual market, insurers had to offer everyone coverage — and couldn’t charge sick people more. And now, many of them are already beginning to rearrange their lives around the law’s uncertain future.” —Sarah Kliff, Vox