In the days after Donald Trump's election as president, Americans suffering from chronic health conditions began to worry that they might be left for dead. Republicans had spent the past six years hammering Obamacare, and now that they controlled the White House and both houses of Congress, it seemed like only a short matter of time before they would ax it once and for all. Those fears were soon given voice by increasingly mainstream left-wing favorites like Bernie Sanders, who tweeted about a week before the inauguration that 36,000 people would die annually if Obamacare were repealed.
Of course, all that panic emerged before anyone had concrete information about what, exactly, Republicans were planning to pass in Congress. At the time, there were five competing GOP plans floating around. (A version of the repeal had actually passed in previous years, albeit mostly as a symbolic gesture, since President Obama was never going to sign a death certificate for his signature domestic achievement.) Republican leaders were finally in a position to kill their least favorite law ever but strangely decided to hide the repeal legislation in a basement, where no one could find it. Once it did see the light of day, the non-partisan Congressional Budget Office (CBO) had a chance to score the American Health Care Act (AHCA), the official Republican plan. But the CBO analyzed the law almost entirely for its effect on the budget, rather than life and death.
Although every think tank that works on health policy has taken a crack at guessing how many people could end up without health insurance if Obamacare went away, the CBO report gave us a go-to number of 24 million over the course of the next decade. That figure includes several broad categories of people who probably would have insurance ten years from now under current law but are much less likely to have it if the AHCA passes. They include people who would receive less generous subsidies to purchase insurance through insurance exchanges, people whose employers will no longer be incentivized to provide plans, lower-income individuals who benefitted from a more generous Medicaid program, and risk takers who probably won't buy a plan once the law stops requiring it.
David Himmelstein is a physician who teaches at the City University of New York and Harvard Medical School and has spent decades studying the connection between healthcare and mortality. He told me that while it's impossible to reach a single definitive figure before a new law like this is finalized, we can get pretty damn close.
His method comes from tweaking data in an authoritative 2012 study in the New England Journal of Medicine (NEJM) that focused on those who benefitted from expanded Medicaid programs in New York, Arizona, and Maine. By applying the percentage change in that report to the average adult death rate, he came up with the estimate that for every 455 people who gained healthcare coverage, one person's life was saved.
"That's probably not a bad rough estimate for the population that would lose coverage with the replacement of the ACA because there'd be a lot of young people who'd lose Medicaid and also a fair number of older people who wouldn't be able to afford the coverage through the exchanges," he told me. "It's not an unreasonable assumption."
Meanwhile, Benjamin Daniel Sommers, a Harvard-based health economist who co-authored the NEJM report Himmelstein used for his calculation, suggested a different approach. He published a paper two years ago in the Annals of Internal Medicine on how death rates changed in Massachusetts after the state implemented healthcare reform in a program not too different from what Obamacare does nationally. Sommers says that data is more applicable to this hypothetical since it speaks to both public and private health insurance.
Although he hedges that—obviously—it's a messy extrapolation. But Sommers gave me a number from that paper to make a back-of-the-envelope calculation anyway. In Massachusetts, at least, one life was saved for every 830 people covered by the statewide expansion, according to his research.
Two more things to note here: Death from Obamacare repeal might be concentrated in states carried by President Trump in the election, and some liberal state governments might try to plug the coverage gap as best as they can. But it's unlikely that Democrats in any given state will be able to quickly pass something similar to what's already in place in Massachusetts––a plan Matthew Fiedler at the Brookings Institute calls "the exception that proves the rule" when it comes to the tricky politics of healthcare.
He says that much of "Romneycare"—as the state's health law was dubbed, after the Republican governor who signed it—was financed through a Medicaid waiver given by the federal government, and that it now relies heavily on Obamacare funding streams to keep plugging along. Places like New York and California have (relatively) high tax rates already, so it may not be viable for them to raise state income taxes to foot the bill for such a costly program. Perhaps more likely, if Medicaid expansion is clawed back by the feds, some states will fight back with lawsuits.
But assuming the CBO score is on point, Himmelstein's death estimate is 52,747 and Sommers's is 28,915—which is to say these are the experts' estimates for the number of deaths that would likely be avoided if Obamacare remained in effect. These are wildly different numbers, obviously, and it should be noted that there may be a difference in death rates when it comes to gaining insurance versus versus losing it. Still, two of the most prominent experts on the relationship between health insurance and morality stand by these figures, rough though they may be.
"Neither of these data points are identical to the current circumstances, so both extrapolations are somewhat imprecise," says Sommers. "That said, I think it's a fair statement from our studies that tens of thousands of lives could be at stake with the ACA repeal debate and the proposed replacement."
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