In rare joint letter, insurers say the Cruz amendment to the Senate Healthcare bill is “unworkable in any form” and will lead to “widespread terminations of coverage.”
In rare joint letter, insurers say the Cruz amendment to the Senate Healthcare bill is “unworkable in any form” and will lead to “widespread terminations of coverage.”
— Richard Trumka — President, AFL-CIO
We are—and always will be—stronger together. You’ve proved that again by standing united in opposition to the GOP health care bill.
More than 400,000 working people like you signed petitions aimed at Congress. More than 26,000 people made phone calls to their senator or representative urging them to oppose a health care bill that will leave 22 million Americans without the care they depend on. And thousands more of you showed up at events across the nation to speak up for all working families’ freedom to have decent health care.
Despite all we’ve done, the fight is far from over. You can help keep up the momentum by sharing this image with your friends and family.
Not only does this plan put millions of working families at risk of losing their care, it also would destroy 1.45 million jobs in the health sector in order to pay for more tax breaks for the wealthy.
Senate Majority Leader Mitch McConnell doesn’t have enough votes today to guarantee a win if he brings this terrible piece of legislation to the floor for a vote, because working women and men continue to take action. It’s up to all of us to keep it that way. Sharing this graphic right now on social media is a great, simple way to do just that.
— by Anjeanette Damon
News has broken that Anthem will stop offering health plans under the Affordable Care Act in nearly all of Nevada’s rural counties, specifically blaming the uncertainty caused by the Republican health care plan in the U.S. Senate. Roughly 8,000 rural Nevadans will lose their access to insurance, with no alternatives to buy a different plan on the exchange. Prominence also decided to pull out of the state’s exchange entirely.
From Stewart Boss, Nevada State Democratic Party spokesperson: “Nevada families are already feeling the harmful effects of the Republican health care agenda in Washington, and Senator Heller – who has voted 20 times to repeal or undermine the Affordable Care Act – is a major part of the problem. The uncertainty and instability caused by Dean Heller and Senate Republicans continuing their efforts to pass their toxic health care plan, combined with the GOP’s efforts to disrupt the exchanges, is now creating havoc in Nevada’s rural counties. The thousands of Nevadans who will lose their health care plans or lose access to health insurance through the exchange have Dean Heller and Donald Trump to blame for this turmoil.”
Longer-Term Effects of the Better Care Reconciliation Act of 2017 on Medicaid Spending
In CBO’s assessment, Medicaid spending under the Better Care Reconciliation Act of 2017 would be 26 percent lower in 2026 than it would be under the agency’s extended baseline, and the gap would widen to about 35 percent in 2036 (see figure below). Under CBO’s extended baseline, overall Medicaid spending would grow 5.1 percent per year during the next two decades, in part because prices for medical services would increase. Under this legislation, such spending would increase at a rate of 1.9 percent per year through 2026 and about 3.5 percent per year in the decade after that.
CBO and the staff of the Joint Committee on Taxation do not have an insurance coverage baseline beyond the coming decade and therefore are not able to quantify the legislation’s effect on insurance coverage over the longer term. However, the agencies expect that after 2026, enrollment in Medicaid would continue to fall relative to what would happen under the extended baseline.
On the basis of consultation with the budget committees, CBO’s just-released cost estimate for the bill measured the costs and savings relative to CBO’s March 2016 baseline projections, with adjustments for legislation that was enacted after that baseline was produced. For consistency, this longer-term analysis uses CBO’s extended baseline published in July 2016. CBO analyzed these longer-term effects at the request of the Ranking Members of the Senate Budget Committee and the Senate Finance Committee.
Related CBO Publications:
— as Posted at the Website of the Congressional Budget Office on June 26, 2017
The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have completed an estimate of the direct spending and revenue effects of the Better Care Reconciliation Act of 2017, a Senate amendment in the nature of a substitute to H.R. 1628. CBO and JCT estimate that enacting this legislation would reduce the cumulative federal deficit over the 2017-2026 period by $321 billion. That amount is $202 billion more than the estimated net savings for the version of H.R. 1628 that was passed by the House of Representatives.
The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.
Following the overview, this document provides details about the major provisions of this legislation, the estimated costs to the federal government, the basis for the estimate, and other related information, including a comparison with CBO’s estimate for the House-passed act.
CBO and JCT estimate that, over the 2017-2026 period, enacting this legislation would reduce direct spending by $1,022 billion and reduce revenues by $701 billion, for a net reduction of $321 billion in the deficit over that period (see Table 1, at the end of this document):
Pay-as-you-go procedures apply because enacting this legislation would affect direct spending and revenues. CBO and JCT estimate that enactment would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2027. The agencies expect that savings, particularly from Medicaid, would continue to grow, while the costs would be smaller because a rescinded tax on employees’ health insurance premiums and health plan benefits would be reinstated in 2026. CBO has not completed an estimate of the potential impact of this legislation on discretionary spending, which would be subject to future appropriation action.
CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026. In later years, other changes in the legislation—lower spending on Medicaid and substantially smaller average subsidies for coverage in the non-group market—would also lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.
Decisions about offering and purchasing health insurance depend on the stability of the health insurance market—that is, on the proportion of people living in areas with participating insurers and on the likelihood of premiums’ not rising in an unsustainable spiral. The market for insurance purchased individually with premiums not based on one’s health status would be unstable if, for example, the people who wanted to buy coverage at any offered price would have average health care expenditures so high that offering the insurance would be unprofitable.
Under Current Law. Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the non-group market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan (which is the second-lowest-cost plan in their area providing specified benefits). The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.
Nevertheless, a small number of people live in areas of the country that have limited participation by insurers in the non-group market under current law. Several factors may lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in non-group coverage through the marketplaces established by the ACA.
Under This Legislation. CBO and JCT anticipate that, under this legislation, non-group insurance markets would continue to be stable in most parts of the country. Although substantial uncertainty about the effects of the new law could lead some insurers to withdraw from or not enter the non-group market in some states, several factors would bring about market stability in most states before 2020. In the agencies’ view, those key factors include the following: subsidies to purchase insurance, which would maintain sufficient demand for insurance by people with low health care expenditures; the appropriation of funds for cost-sharing subsidies, which would provide certainty about the availability of those funds; and additional federal funding provided to states and insurers, which would lower premiums by reducing the costs to insurers of people with high health care expenditures.
The agencies expect that the non-group market in most areas of the country would continue to be stable in 2020 and later years as well, including in some states that obtain waivers that would not have otherwise done so. (Under current law and this legislation, states can apply for Section 1332 waivers to change the structure of subsidies for non-group coverage; the specifications for essential health benefits [EHBs], which set the minimum standards for the benefits that insurance in the non-group and small-group markets must cover; and other related provisions of law.) Substantial federal funding to directly reduce premiums would be available through 2021. Premium tax credits would continue to provide insulation from changes in premiums through 2021 and in later years. Those factors would help attract enough relatively healthy people for the market in most areas of the country to be stable, CBO and JCT anticipate. That stability in most areas would occur even though the premium tax credits would be smaller in most cases than under current law and subsidies to reduce cost sharing—the amount that consumers are required to pay out of pocket when they use health care services—would be eliminated starting in 2020.
In the agencies’ assessment, a small fraction of the population resides in areas in which—because of this legislation, at least for some of the years after 2019—no insurers would participate in the non-group market or insurance would be offered only with very high premiums. Some sparsely populated areas might have no non-group insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance—and markets with few purchasers are less profitable for insurers. Insurance covering certain services would become more expensive—in some cases, extremely expensive—in some areas because the scope of the EHBs would be narrowed through waivers affecting close to half the population, CBO and JCT expect. In addition, the agencies anticipate that all insurance in the nongroup market would become very expensive for at least a short period of time for a small fraction of the population residing in areas in which states’ implementation of waivers with major changes caused market disruption.
The legislation would increase average premiums in the non-group market prior to 2020 and lower average premiums thereafter, relative to projections under current law, CBO and JCT estimate. To arrive at those estimates, the agencies examined how the legislation would affect the premiums charged if people purchased a benchmark plan in the non-group market.
In 2018 and 2019, under current law and under the legislation, the benchmark plan has an actuarial value of 70 percent—that is, the insurance pays about 70 percent of the total cost of covered benefits, on average. In the marketplaces, such coverage is known as a silver plan.
Under the Senate bill, average premiums for benchmark plans for single individuals would be about 20 percent higher in 2018 than under current law, mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up. Those premiums would be about 10 percent higher than under current law in 2019—less than in 2018 in part because funding provided by the bill to reduce premiums would affect pricing and because changes in the limits on how premiums can vary by age would result in a larger number of younger people paying lower premiums to purchase policies.
In 2020, average premiums for benchmark plans for single individuals would be about 30 percent lower than under current law. A combination of factors would lead to that decrease—most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.
That share of services covered by insurance would be smaller because the benchmark plan under this legislation would have an actuarial value of 58 percent beginning in 2020. That value is slightly below the actuarial value of 60 percent for “bronze” plans currently offered in the marketplaces. Because of the ACA’s limits on out-of-pocket spending and prohibitions on annual and lifetime limits on payments for services within the EHBs, all plans must pay for most of the cost of high-cost services. To design a plan with an actuarial value of 60 percent or less and pay for those high-cost services, insurers must set high deductibles—that is, the amounts that people pay out of pocket for most types of health care services before insurance makes any contribution. Under current law for a single policyholder in 2017, the average deductible (for medical and drug expenses combined) is about $6,000 for a bronze plan and $3,600 for a silver plan. CBO and JCT expect that the benchmark plans under this legislation would have high deductibles similar to those for the bronze plans offered under current law. Premiums for a plan with an actuarial value of 58 percent are lower than they are for a plan with an actuarial value of 70 percent (the value for the reference plan under current law) largely because the insurance pays for a smaller average share of health care costs.
Although the average benchmark premium directly affects the amount of premium tax credits and is a key element in CBO’s analysis of the budgetary effects of the bill, it does not represent the effect of this legislation on the average premiums for all plans purchased. The differences in the actuarial value of plans purchased under this legislation and under current law would be greater starting in 2020—when, for example, under this bill, some people would pay more than the benchmark premium to purchase a silver plan, whereas, under current law, others would pay less than the benchmark premium to purchase a bronze plan.
Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income—also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.
By 2026, average premiums for benchmark plans for single individuals in most of the country under this legislation would be about 20 percent lower than under current law, CBO and JCT estimate—a smaller decrease than in 2020 largely because federal funding to reduce premiums would have lessened. The estimates for both of those years encompass effects in different areas of the country that would be substantially higher and substantially lower than the average effect nationally, in part because of the effects of state waivers. Some small fraction of the population is not included in those estimates. CBO and JCT expect that those people would be in states using waivers in such a way that no benchmark plan would be defined. Hence, a comparison of benchmark premiums is not possible in such areas.
Some people enrolled in non-group insurance would experience substantial increases in what they would spend on health care even though benchmark premiums would decline, on average, in 2020 and later years. Because non-group insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law. Out-of-pocket spending would also be affected for the people—close to half the population, CBO and JCT expect—living in states modifying the EHBs using waivers. People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services. Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state. As a result, for some benefits that might be removed from a state’s definition of EHBs but that might not be excluded from insurance coverage altogether, some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed.
CBO and JCT have endeavored to develop budgetary estimates that are in the middle of the distribution of potential outcomes. Such estimates are inherently inexact because the ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to the changes made by this legislation are all difficult to predict. In particular, predicting the overall effects of the myriad ways that states could implement waivers is especially difficult.
CBO and JCT’s projections under current law itself are also uncertain. For example, enrollment in the marketplaces under current law will probably be lower than was projected under the March 2016 baseline used in this analysis, which would tend to decrease the budgetary savings from this legislation. However, the average subsidy per enrollee under current law will probably be higher than was projected in March 2016, which would tend to increase the budgetary savings from this legislation. (For a related discussion, see the section on “Use of the March 2016 Baseline” on page 15.)
Despite the uncertainty, the direction of certain effects of this legislation is clear. For example, the amount of federal revenues collected and the amount of spending on Medicaid would almost surely both be lower than under current law. And the number of uninsured people under this legislation would almost surely be greater than under current law.
CBO has reviewed the non-tax provisions of the legislation and determined that they would impose intergovernmental mandates as defined in the Unfunded Mandates Reform Act (UMRA) by preempting state laws. Although the pre-emptions would limit the application of state laws, they would impose no duty on states that would result in additional spending or a loss of revenues. JCT has determined that the tax provisions of the legislation contain no intergovernmental mandates.
JCT and CBO have determined that the legislation would impose private-sector mandates as defined in UMRA. On the basis of information from JCT, CBO estimates that the aggregate cost of the mandates would exceed the annual threshold established in UMRA for private-sector mandates ($156 million in 2017, adjusted annually for inflation).
Sen. Al Franken discusses how dangerous Trumpcare actually is:
The GOP’s AHCA, if enacted, will strip people of their protections, not so much in the language as written striking those protections directly, but through the granting of “waivers.” Various states, specifically “red” states, want to be able apply for waivers such that they don’t have to provide healthcare plans that provide coverage for any “essential healthcare benefit” identified in the ACA that they don’t particularly like. That means MEN in GOP-dominated legislatures who don’t think “maternity care” should be an essential benefit because MEN don’t get pregnant, can seek waivers for having to provide plans that cover maternity care. The same might hold true for those opposing inclusion of Emergency Room care, or prescription drugs, or 1st-day expenses associated with a hospital admission (the most expensive day), or cancer screenings, etc. Similarly, waivers could be sought regarding annual or lifetime limits of coverage. We already know that they’re seeking an amendment that would block all coverage for 3-months should someone come up short after getting fired from a job and miss a payment to their healthcare insurer.
If the AHCA passes in the Senate and goes back to the House for a vote, the House could choose to short-circuit the process and end their struggle to “repeal and replace” by merely voting to accept the Senate-passed bill and it would head to interloper in the White House’s desk for his glorious 2″ tall signature in some binder he can hold up for all to see.
One thing all of us need to understand is that enactment of the AHCA will be the first step in the race to the bottom for ALL of us (not just those on medicaid or those buying insurance via exchanges) — even those who currently have employer-based insurance will be dramatically impacted. You see, employers already buy insurance “across state lines” because they typically have plans that insure employees in multiple states. That means, they’ll be looking at which states sought waivers and for what type of coverage they sought waivers that will drive their cost of insuring their workforce down. When they start buying insurance from waivered-state insurance providers, those essential health benefits you’ve become accustomed to having and using are going to start disappearing. Your costs/cost-sharing/deductibles/etc. are all going to dig deeper into your pockets, and that’s before all those age-rated factors start kicking in, or your workplace becomes too hostile for you to tolerate any more as they lean on you more heavily attempting to get you to leave so they can hire a less expensive to insure younger employee.
Those of us who live in rural America already know how hard it is to obtain services or to even find a healthcare insurer … at any price. Corporations have no interest in doing business in rural America where doctors are fewer, where hospitals and clinics serve smaller populations and where serious emergency cases have some seriously high transportation costs associated with getting them to the nearest trauma center. It can only get worse for us.
Bottom-line? People are going to lose their ability to afford insurance. AND … people are going to needlessly die early deaths.
Our politics are divided. They have been for a long time. And while I know that division makes it difficult to listen to Americans with whom we disagree, that’s what we need to do today.
I recognize that repealing and replacing the Affordable Care Act has become a core tenet of the Republican Party. Still, I hope that our Senators, many of whom I know well, step back and measure what’s really at stake, and consider that the rationale for action, on health care or any other issue, must be something more than simply undoing something that Democrats did.
We didn’t fight for the Affordable Care Act for more than a year in the public square for any personal or political gain – we fought for it because we knew it would save lives, prevent financial misery, and ultimately set this country we love on a better, healthier course.
Nor did we fight for it alone. Thousands upon thousands of Americans, including Republicans, threw themselves into that collective effort, not for political reasons, but for intensely personal ones – a sick child, a parent lost to cancer, the memory of medical bills that threatened to derail their dreams.
And you made a difference. For the first time, more than ninety percent of Americans know the security of health insurance. Health care costs, while still rising, have been rising at the slowest pace in fifty years. Women can’t be charged more for their insurance, young adults can stay on their parents’ plan until they turn 26, contraceptive care and preventive care are now free. Paying more, or being denied insurance altogether due to a preexisting condition – we made that a thing of the past.
We did these things together. So many of you made that change possible.
At the same time, I was careful to say again and again that while the Affordable Care Act represented a significant step forward for America, it was not perfect, nor could it be the end of our efforts – and that if Republicans could put together a plan that is demonstrably better than the improvements we made to our health care system, that covers as many people at less cost, I would gladly and publicly support it.
That remains true. So I still hope that there are enough Republicans in Congress who remember that public service is not about sport or notching a political win, that there’s a reason we all chose to serve in the first place, and that hopefully, it’s to make people’s lives better, not worse.
But right now, after eight years, the legislation rushed through the House and the Senate without public hearings or debate would do the opposite. It would raise costs, reduce coverage, roll back protections, and ruin Medicaid as we know it. That’s not my opinion, but rather the conclusion of all objective analyses, from the nonpartisan Congressional Budget Office, which found that 23 million Americans would lose insurance, to America’s doctors, nurses, and hospitals on the front lines of our health care system.
The Senate bill, unveiled today, is not a health care bill. It’s a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else. Those with private insurance will experience higher premiums and higher deductibles, with lower tax credits to help working families cover the costs, even as their plans might no longer cover pregnancy, mental health care, or expensive prescriptions. Discrimination based on pre-existing conditions could become the norm again. Millions of families will lose coverage entirely.
Simply put, if there’s a chance you might get sick, get old, or start a family – this bill will do you harm. And small tweaks over the course of the next couple weeks, under the guise of making these bills easier to stomach, cannot change the fundamental meanness at the core of this legislation.
I hope our Senators ask themselves – what will happen to the Americans grappling with opioid addiction who suddenly lose their coverage? What will happen to pregnant mothers, children with disabilities, poor adults and seniors who need long-term care once they can no longer count on Medicaid? What will happen if you have a medical emergency when insurance companies are once again allowed to exclude the benefits you need, send you unlimited bills, or set unaffordable deductibles? What impossible choices will working parents be forced to make if their child’s cancer treatment costs them more than their life savings?
To put the American people through that pain – while giving billionaires and corporations a massive tax cut in return – that’s tough to fathom. But it’s what’s at stake right now. So it remains my fervent hope that we step back and try to deliver on what the American people need.
That might take some time and compromise between Democrats and Republicans. But I believe that’s what people want to see. I believe it would demonstrate the kind of leadership that appeals to Americans across party lines. And I believe that it’s possible – if you are willing to make a difference again. If you’re willing to call your members of Congress. If you are willing to visit their offices. If you are willing to speak out, let them and the country know, in very real terms, what this means for you and your family.
After all, this debate has always been about something bigger than politics. It’s about the character of our country – who we are, and who we aspire to be. And that’s always worth fighting for.
—byy Ann Crawford-Roberts, Nichole Roxas, Ichiro Kawachi, Sam Berger, and Emily Gee
One Republican member of Congress, defending the GOP health care plan—the American Health Care Act (AHCA)—suggested that concerns that the loss of health care coverage leads to death are overblown. However, the scientific literature on the effects of insurance coverage on mortality shows that the coverage losses from the AHCA would result in tens of thousands of deaths.
The secret Senate bill was finally released today, and it is broadly similar to what passed in the House: It ends Medicaid expansion and makes further deep cuts to the program; eliminates the individual mandate; and reduces funding that helps low-income Americans afford health coverage. The Congressional Budget Office (CBO) has not yet released its score of the Senate bill, although it is expected to do so early next week.
The CBO, however, has released a score of the House’s version of the AHCA, which is largely similar to the Senate bill. The score projected that, by 2026, 23 million more Americans would be uninsured under the House bill compared to the Affordable Care Act (ACA). Using estimates of mortality rates from Massachusetts’ experience with health reform, we estimate the number of additional deaths resulting from coverage losses from the Senate bill under three scenarios: one scenario in which coverage losses from the Senate bill are the same as under the House version, and two scenarios in which those coverage losses are modestly reduced by changes from the House bill.
Allocating these coverage losses among the states, this analysis also presents estimates of additional deaths by state.
Health insurance is associated with improved health and reduced mortality
A significant body of research has demonstrated the health benefits associated with health insurance expansion, including reducing the rate of death among the population. One study found that state Medicaid expansions that preceded the ACA were associated with a significant reduction in mortality. A recent analysis of these pre-ACA Medicaid expansions demonstrated a 6 percent decline in all-cause mortality due to Medicaid expansion. Another analysis showed that following implementation of the ACA’s provision that allows young adults to remain on a parent’s health insurance until age 26, mortality rates decreased among Americans ages 19 to 25. In particular, mortality caused by diseases amenable to health care dropped among young adults, while trauma-related mortality did not. And a study of patients with cancer between the ages of 20 to 40 found a statistically significant association between insurance coverage and reduced mortality from any cause.
The result most relevant to the ACA and its repeal comes from a study examining the effects of the Massachusetts health care reform on all-cause mortality and on mortality due to causes amenable to health care. The study found that expanding insurance coverage was associated with a 2.9 percent decrease in all-cause mortality and a 4.5 percent reduction in deaths from causes amenable to health care. Because Massachusetts’s reform was used as the model for the ACA and included a coverage mandate, Medicaid expansion, and private insurance expansion through the individual market, the data is more representative of the effects of ACA insurance gains than studies looking solely at Medicaid expansion or narrow demographic groups. Furthermore, observers have noted that the study’s quasi-experimental study design is of high quality and the “next best thing” to a randomized control study.
Other parts of the scientific literature have shown how having health insurance, unsurprisingly, results in better health. A recent study of three years of ACA data demonstrated that uninsured people who gained coverage through the ACA experienced a 23 percent increase in self-reported “excellent” health. One analysis found that the ACA coverage expansion was associated with reductions in self-reported “fair” or “poor” health and days with activity limitations due to ill health. Another analysis showed that ACA insurance gains were associated with an increased share of respondents reporting excellent health. And a recent study of ACA-facilitated Medicaid expansions found that they modestly improved self-reported health.
Other insurance expansions produced similar results. Massachusetts’ insurance expansion was associated with improvements in self-reported general, physical, and mental health. Data from the Oregon Health Insurance Experiment showed that expanding Medicaid was associated with improved self-reported physical and mental health and reduced depression.
Insurance coverage also improves children’s health and access to care. Research shows that when parents have insurance coverage, their children are more likely to be covered, maintain stable coverage, and receive needed care. According to the Institute of Medicine’s systematic review, insured children are more likely to gain access to well-child care and immunizations, appropriate care for asthma, and basic dental services, as well as have fewer avoidable hospitalizations, improved asthma outcomes, and fewer missed days of school.
Taken as a whole, the research strongly suggests that health coverage has a significant positive effect on health. However, a few studies have found more limited health impacts of insurance expansion. While the Oregon study found improvements in self-reported health, it did not detect clinical improvements other than depression reduction. Another study showed no changes in self-reported health resulting from the ACA, although a subgroup analysis did show improved self-assessed health among older nonelderly adults, especially in expansion states. And an early observational study of the ACA’s Medicaid expansion comparing low-income adults in expansion and nonexpansion states found no differences in self-reported health between the groups.
There may be several reasons for these outlier results. The studies in question looked at time frames too short or sample sizes too small to capture more significant health impacts. In addition, insurance is a necessary but not sufficient factor to receive quality health care. Receiving high-quality health care requires access to providers, institutions, and services; access to consistent primary care and referral services; choice of providers and institutions; and the delivery of high-quality services. It also requires that insurance policies cover basic and vital services.
The effects of the repeal bill on mortality
Drawing on the Massachusetts experience, we estimate that there would be one excess death for every 830 people who lose coverage as a result of the AHCA. The CBO projections of coverage reductions under the House version of the AHCA would equate to 217,000 additional deaths over the next decade, including 27,700 additional deaths in 2026. (see Table 1) To put this in perspective, that is approximately the number of people in the United States who died from opioid overdoses in 2014 and about twice the number of deaths by that same year.
We also estimate the additional deaths in 2026 resulting from coverage losses from the Senate bill under three scenarios: one assuming coverage losses equivalent to the House bill and two scenarios that show modest reductions in coverage losses. If the Senate bill results in coverage losses of 19 million that would result in 22,900 additional deaths in 2026. If the Senate bill results in coverage losses of 15 million that would result in 18,100 additional deaths in 2026.
In addition, drawing on the Center for American Progress’ estimate of state-level coverage reductions in 2026 under the House version of the AHCA, we estimate additional deaths by state in 2026 as a result of coverage losses from the Senate bill under the three scenarios. Under the scenario assuming coverage losses of 23 million, annual additional deaths would range from 36 in North Dakota to 3,111 in California in 2026. Under the scenario assuming coverage losses of 19 million, annual additional deaths in 2026 would range from 30 in North Dakota to 2,570 in California. Finally, under the scenario assuming coverage losses of 15 million, annual additional deaths in 2026 would range from 24 in North Dakota to 2,029 in California.
Given the overwhelming weight of evidence, there should be no debate: Health care coverage has an impact on whether Americans live or die. Our data estimates show that under any of the scenarios we analyzed, a significant number of American lives are at stake in this debate. Legislators considering whether to support this bill should keep in mind and soberly consider the catastrophic effect the AHCA would have on so many Americans and their families.
We calculated national excess deaths per year by dividing the estimated coverage losses by the estimated numbers needed to treat (NNT) to prevent one death, based on analyses of the Massachusetts health care reform. “Treatment” in this instance refers to the number of individuals who would need to receive insurance coverage in order to prevent one extra death. The Massachusetts study found that there was one fewer death for every 830 people who gained coverage; that NNT was consistent with a 30 percent relative reduction in individual-level mortality for persons gaining insurance.
We estimate that there would be one excess death for every 830 people who lose insurance coverage, which assumes that the Massachusetts result would be symmetric for health insurance gains and losses. Of note, our approach is similar to that taken by the White House Council of Economic Advisers to calculate the mortality reductions from the ACA.
Our estimate of the national number of excess deaths each year under the AHCA is then equal to the CBO-projected coverage reduction under the House bill divided by 830. We calculated state level estimates by applying the same methodology to state-level health insurance losses from the Center for American Progress’ state-level analysis, which combines data from the CBO, the Kaiser Family Foundation, the Centers for Medicare and Medicaid Services, and the American Community Survey to calculate anticipated insurance losses by coverage type.
We also included estimates of the number of excess deaths in 2026 if national coverage losses under the Senate bill were 15 million or 19 million that year. For our state-level estimates, we assume that each state’s coverage reductions and excess deaths are 65 percent and 83 percent of our estimates of the effects under the House-passed bill, respectively.
Recent debate sheds light on different approaches to estimate the mortality impacts of insurance loss. Bearing this debate in mind, we designed our approach using the most accurate, rigorous studies. We base our calculations on estimates of AHCA-related coverage losses from the CBO and the Center for American Progress, and on Benjamin D. Sommers, Sharon K. Long, and Katherine Baicker’s 2014 quasi-experimental study of the effects of Massachusetts Health Care Reform on mortality. We chose this study due to its sample size and power, and because Massachusetts’ health reform, which expanded both private and public coverage, was used as the model for the ACA.
One limitation of our analysis is that the same NNT was applied to all states, although the estimate was derived from the Massachusetts’ health care reform. There are demographic and health care infrastructure differences between Massachusetts and other states. The Massachusetts population has a higher per capita physician rate, lower baseline mortality rate, higher income and baseline insurance coverage rates, fewer racial and ethnic minorities, and more women, compared to national averages. Some of these factors suggest that Massachusetts may have a higher NNT than other states, meaning that our estimate of the number of excess deaths under the AHCA would be too low, while other factors suggest the state may have a lower NNT.
In addition, the NNT was calculated from mortality decreases associated with insurance expansion. There is uncertainty as to whether withdrawing insurance will cause the equal and opposite effect of providing insurance. Lastly, our estimates capture only the impact of increased uninsurance under the AHCA and do not take in to account possible mortality effects among people who would remain insured but lose certain benefits or encounter worse access to care due to the bill.
We calculated a 95 percent confidence interval around our estimates of excess mortality. The confidence interval contains the range of reasonable values that include our estimate of excess mortality, with 95 percent confidence. Within this range the best estimate for the actual number of excess deaths is the point estimate. The point estimate is the mean and represents our best prediction for annual excess mortality rates, given the current evidence and available data. For instance, in the year 2026 and assuming 23 million more people are uninsured, we estimate that 27,711 excess deaths will occur, and we are 95 percent confident that the true number of annual excess deaths will be between 9,583 and 46,000.
Ann Crawford-Roberts is a medical student at the Icahn School of Medicine at Mount Sinai and a graduate of the Harvard T.H. Chan School of Public Health. Nichole Roxas is a medical student at the University of Rochester School of Medicine and Dentistry and a graduate of the Harvard T.H. Chan School of Public Health. Ichiro Kawachi is a professor of social epidemiology and the chair of the Department of Social and Behavioral Sciences at Harvard T.H. Chan School of Public Health. Sam Berger is the senior policy adviser at the Center for American Progress. Emily Gee is the health economist for the Health Policy team at the Center.
This material [the article above] was created by the Center for American Progress Action Fund. It was created for the Progress Report, the daily e-mail publication of the Center for American Progress Action Fund. Click here to subscribe. ‘Like’ CAP Action on Facebook and ‘follow’ them on Twitter
We’re in danger of losing our health care. The Senate is inching closer to passing a devastating health care bill. If they do, then millions of people will see their health care coverage disappear. But you can do something about it.
Nevada is particularly important in the fight to save our health care. Why? Because our senator, Dean Heller, is a deciding vote on the Senate bill.
You have a critical part to play, and there is no time to waste. As a constituent, you have the power to influence Senator Heller’s vote on health care.
The over 600,000 Nevadans who rely on Medicaid would be most adversely affected as Nevada is poised to lose approximately $5 billion in federal Medicaid funds by 2028 if the Senate health care bill passes. This would harm 300,000 children, 13,000 seniors, and 42,000 people with disabilities in Nevada.
But that’s only what we actually know today. Are you insured through an employer plan? You do know that employers shop insurers country-wide for the best policy prices they can find, right? Have you heard this bill allows States to seek waivers of EHBs (Essential Health Benefits, like maternity coverage, ER visits, Xrays, cancer screenings, etc.)? What do you think will happen to the healthcare insurance coverage you now have once your employer, like everyone else’s employer starts shopping “EHB-waivered” states for their insurance policies to save money, while holding what you pay constant or even charging you a larger percentage of the cost, all to pad their bottom line?
TrumpedUpCare harms us all and we can’t let that happen! The clock is ticking with an expected vote no later than next Thursday. Call Senator Heller’s offices today and often (call all of them). Let him know that if he takes a meat cleaver to our healthcare, he might as well take a meat cleaver to his 2018 campaign, because he’s done!
Governor Brian Sandoval vetoed Assembly Bill 374, which would have created a Medicaid buy-in option for all Nevadans. Nevada State Democratic Party Chair William McCurdy II released the following statement:
“Republicans like Senator Heller and Congressman Amodei are actively sabotaging the Affordable Care Act and trying to pass a bill that increases your costs, slashes your coverage, and eliminates key health care protections. Assemblyman Sprinkle’s Nevada Care Plan was motivated by the idea that health care should be a right, and his legislation was the product of diligent work, innovative policy ideas, and bipartisan collaboration. If Governor Sandoval had signed this bill, every Nevadan would have gained the opportunity to buy an affordable plan with Medicaid-like health benefits on the insurance market. Governor Sandoval’s disappointing veto leaves Nevadans more vulnerable to the GOP’s heartless and reckless health care policies in Washington.
Governor Sandoval’s disappointing veto leaves Nevadans more vulnerable to the GOP’s heartless and reckless health care policies in Washington” — NV Dems Chair William McCurdy II
Governor Brian Sandoval also vetoed Assembly Bill 206 to set a standard of getting 40% of our energy from renewable sources by 2030 and Senate Bill 392 to expand solar energy access to more communities including low-income families. Nevada State Democratic Party Chair William McCurdy II released a statement relative to those vetoes as well:
“During this past legislative session, Democrats worked in a bipartisan way to revitalize Nevada’s clean energy economy, and I’m proud of everything we accomplished together in Carson City. Governor Sandoval’s vetoes represent missed opportunities for us to seize the economic opportunity of renewable energy in our communities. Community solar would have helped families who rent and low-income neighborhoods reduce their energy bills through access to solar power, and an ambitious Renewable Portfolio Standard would have created tens of thousands of jobs and billions of dollars in wages right here in Nevada. The fight will continue to build on our state’s clean energy progress and enact these common-sense policies next session.
Governor Sandoval’s vetoes represent missed opportunities for us to seize the economic opportunity of renewable energy in our communities” — NV Dems Chair William McCurdy II