Oba­macare lives. No one could agree what was at risk.

The Washington Post Sunday - - TAKING STOCK - BY CAROLYN Y. JOHN­SON carolyn.john­son@wash­post.com

When Congress failed to re­peal and re­place Oba­macare, part of the dif­fi­culty law­mak­ers faced was un­der­stand­ing what was at stake.

In the GOP pro­posal, mil­lions of Amer­i­cans were pro­jected to lose their health in­sur­ance un­der the health-care law’s pro­posed re­peal. Few agreed on how many lives were at risk.

Sen. Bernie San­ders (I-Vt.) tweeted his take: 36,000 more deaths per year. An an­a­lyst at the con­ser­va­tive Man­hat­tan In­sti­tute anal­y­sis ar­gued the true an­swer was zero. In­di­vid­ual anec­dotes abound: Oba­macare saved my life.

In a new anal­y­sis pub­lished last week in the Amer­i­can Jour­nal of Pub­lic Health, a pair of doc­tors who ad­vised San­ders’s pres­i­den­tial cam­paign found that a re­peal of the law with­out a re­place­ment could cost any­where from 14,000 to 60,000 lives — in the next year alone.

It’s un­sur­pris­ing that par­ti­sans ar­gu­ing over what to do with the law — known of­fi­cially as the Af­ford­able Care Act — would dis­agree about the ef­fects of re­peal­ing it. But even non­par­ti­san health pol­icy ex­perts are at a loss when asked for a fig­ure on how many peo­ple would per­ish if the ACA comes off the books.

That’s be­cause the law’s most wide­spread fea­ture is help­ing peo­ple buy health in­sur­ance, and the link be­tween be­ing cov­ered by health in­sur­ance and ac­tu­ally be­ing health­ier is not fully un­der­stood.

It isn’t that the ques­tion hasn’t been stud­ied or that in­di­vid­ual ben­e­fits of health in­sur­ance aren’t known. An In­sti­tute of Medicine re­port in 2009 rounded up the ev­i­dence that unin­sured peo­ple fared worse after a heart at­tack, stroke, cancer, di­a­betes, con­ges­tive heart fail­ure and trauma. But what does all that harm add up to in lives lost or saved?

To make their es­ti­mate, physi­cians St­effie Wool­han­dler and David Him­mel­stein ex­trap­o­lated from a hand­ful of stud­ies pub­lished dur­ing the past 15 years that used a va­ri­ety of data sets and sit­u­a­tions — such as the ex­pan­sion of Med­i­caid in Oregon through a lot­tery and the ef­fects of health-care over­haul in Mas­sachusetts.

“The com­mon-sense be­lief that if you lose your health in­sur­ance, it’s go­ing to make your health worse and it might even kill you — that’s a com­mon-sense be­lief that hap­pens to be true,” Wool­han­dler said in an in­ter­view. “Peo­ple can­not say we’re go­ing to take health care away from 24 mil­lion peo­ple and say no­body’s go­ing to die.”

But health is a cu­mu­la­tive, com­plex and long-term out­come, de­ter­mined not only by health in­sur­ance sta­tus but by so­cioe­co­nomic fac­tors, ge­net­ics, life­style and the neigh­bor­hoods where peo­ple live. The dif­fer­ences be­tween hav­ing in­sur­ance and not hav­ing in­sur­ance of­ten en­cap­su­lates a broad swath of other fac­tors that af­fect peo­ple’s well­be­ing.

“When you ask the ques­tion, then, what would be the ef­fect of re­peal­ing the ACA, there’s no per­fect way to an­swer this ques­tion,” said Ben­jamin Som­mers, an as­so­ciate pro­fes­sor of health pol­icy and eco­nom­ics at the Har­vard T.H. Chan School of Pub­lic Health.

One of the stud­ies the re­searchers drew on to make their es­ti­mate was led by Amy Finkel­stein, an econ­o­mist at MIT. Finkel­stein said that the body of re­search, in­clud­ing her work on the ef­fects of the 2008 Med­i­caid ex­pan­sion in Oregon, have made her con­fi­dent that health in­sur­ance im­proves health. That study found a sig­nif­i­cant drop in de­pres­sion and an in­crease in peo­ple’s self-re­ported health among those who ran­domly re­ceived Med­i­caid com­pared with those who did not.

But re­ceiv­ing in­sur­ance did not lead to im­prove­ments in other ar­eas, such as bet­ter man­age­ment of blood pres­sure, choles­terol lev­els or blood su­gar con­trol over the two years of the study. And since death was — for­tu­nately — a rel­a­tively rare event for peo­ple be­tween the ages of 19 and 64 in the Oregon study, where the sur­vival rate was higher than 99 per­cent, mea­sur­ing the ef­fect of in­sur­ance on mor­tal­ity may not be the right way to make the case it was work­ing.

“You can’t rule out that Med­i­caid saves a bunch of lives, but you also can’t rule out that it kills a bunch of peo­ple,” Finkel­stein said of the Oregon data. She ar­gued that while health in­sur­ance is aimed at im­prov­ing health, it is also fun­da­men­tally a prod­uct aimed at pro­tect­ing peo­ple against fi­nan­cial ruin, and an­other way to mea­sure its ef­fects — par­tic­u­larly in the short term — would be to ex­am­ine how it helped fi­nan­cial se­cu­rity.

The Oregon study showed re­duc­tions in fi­nan­cial strain, and a work­ing pa­per pub­lished last year es­ti­mated that peo­ple who gained cov­er­age through the broader Med­i­caid ex­pan­sion had any­where from a $600 to $1,000 re­duc­tion in col­lec­tion debt.

Som­mers, whose work was also used to es­ti­mate the ef­fect of ACA re­peal, said that an­other chal­lenge is know­ing whether giv­ing some­one in­sur­ance — which is what hap­pened in his study of health-care over­haul in Mas­sachusetts — will have di­rectly the op­po­site ef­fect as tak­ing it away.

Two of the stud­ies the re­searchers cited ex­am­ined large data sets and found an as­so­ci­a­tion be­tween longer life and hav­ing health cov­er­age but could not de­ter­mine that the in­sur­ance drove the ef­fect. That leaves open the pos­si­bil­ity that it isn’t cov­er­age it­self that caused the dis­par­ity but might also be ex­plained by other dif­fer­ences be­tween peo­ple who have in­sur­ance and those who don’t.

In his work, Som­mers com­pared the death rates of peo­ple in Mas­sachusetts be­fore and after the state im­ple­mented health­care changes in 2006 with peo­ple in sim­i­larly matched coun­ties that did not ex­pand in­sur­ance cov­er­age. He found a de­crease in deaths in Mas­sachusetts — in just the kinds of deaths, such as cancer, di­a­betes, heart dis­ease that they ex­pected might shift be­cause of ac­cess to in­sur­ance.

“The short an­swer is, th­ese are chal­leng­ing ex­trap­o­la­tions,” Som­mers said. “But I think what’s fair to say, based on our stud­ies, is that giv­ing peo­ple in­sur­ance can re­duce mor­tal­ity, so likely tak­ing it away will cause an in­crease . . . . The ex­act num­ber is much harder to pin down.”

BILL O’LEARY/THE WASH­ING­TON POST

Sup­port­ers of the Af­ford­able Care Act, also known as Oba­macare, protest in the Dis­trict on Feb. 25 as part of a na­tion­wide day of ral­lies op­pos­ing the law’s re­peal.

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