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"How the Senate’s Health-Care Bill Threatens the Nation’s Health"Atul Gawande, Surgeon & Public Health Researcher
The New Yorker
To understand how the Senate Republicans’ health-care bill would affect people’s actual health, the first thing you have to understand is that incremental care—regular, ongoing care as opposed to heroic, emergency care—is the greatest source of value in modern medicine. There is clear evidence that people who get sufficient incremental care enjoy better prevention, earlier diagnosis and management of urgent conditions, better control of chronic illnesses, and longer life spans.
When more people get health-insurance coverage, as they did following the implementation of the Affordable Care Act, they get more incremental care. This week, the New England Journal of Medicine published a paper that I co-authored with Katherine Baicker and Ben Sommers, two health economists at the Harvard T. H. Chan School of Public Health, in which we analyzed the health effects of insurance coverage. We looked at dozens of studies put out over the last decade, and found that insurance-coverage expansions—including not just the A.C.A but also past Medicaid expansions and the health-care reform that Massachusetts passed in 2006—have consistently and significantly increased the number of people who have a regular source of care and who can afford the care they need. Insurance expansions have made people more likely to get primary and preventive care, chronic-illness care, and needed medications—including cancer screenings, diabetes and blood-pressure medicines, depression treatment, and surgery for cancer before it is too late.
These improvements in care help explain why people who have health insurance are twenty-five per cent more likely to report being in good or excellent health. It also explains why they become less likely to die. Proper health care saves lives, and the magnitude of the reduction in deaths increases over time. The longest study we looked at analyzed Medicaid expansions that occurred in the early two-thousands in Arizona, Maine, and New York. Five years after the expansions, mortality rates for recipients had fallen by six per cent compared with matched populations in states that didn’t expand Medicaid. More broadly, when we looked at the data from all the large studies in our set, we found that, for every three hundred to eight hundred people who gained coverage, one life was ultimately saved per year. The biggest gains came, as would be expected, among patients with chronic or semi-chronic conditions, such as heart disease, cancer, H.I.V., and other infections.
Conservatives often take a narrow view of the value of health insurance: they focus on catastrophic events such as emergencies and sudden, high-cost illnesses. But the path of life isn’t one of steady health punctuated by brief crises. Most of us accumulate costly, often chronic health issues as we age. These issues can often be delayed, managed, and controlled if we have good health care—and can’t be if we don’t.
Conservatives also dismiss Medicaid by arguing that it provides inadequate or unsatisfactory coverage. The opposite is true, according to the evidence. Compared with private coverage, Medicaid produces at least as much improvement in access to care, measures of health, and mortality reduction. And polls indicate that recipients like Medicaid more than private coverage, even with the difficulties finding doctors who take Medicaid, because the program provides them with better financial protection.
Despite these facts, the Senate reform bill, like the bill that House Republicans passed earlier this year, would hollow out or terminate coverage for tens of millions of Americans who rely on Medicaid or the private-insurance exchanges set up by the A.C.A. These bills are, in many ways, Medicaid-repeal bills masquerading as Obamacare-repeal bills. And Medicaid, remember, is not a program that the public is complaining about. It is immensely popular and works well.
It provides coverage for sixty per cent of disabled children, and maternity coverage for half of pregnant women. Two-thirds of nursing-home residents end up relying on Medicaid coverage after their savings are spent. Among adult Medicaid recipients, sixty per cent work, and eighty per cent are part of working families.
President Trump, who has expressed his support for the Senate bill, campaigned on a specific promise not to cut Medicaid, and the White House continues to peddle a claim that, as Sean Spicer put it on Friday, the President is “committed to making sure that no one who currently is in the Medicaid program is affected in any way, which is reflected in the Senate bill, and he’s pleased with that.” But this statement does not reflect reality—the Senate proposal would not only roll back the A.C.A.’s Medicaid expansion but go even further, capping Medicaid expenditures at levels even lower than those that would have been in place without the A.C.A.
The Senate bill would also ultimately make people who buy insurance on the A.C.A. exchanges—people without coverage from an employer or from Medicaid—pay far more money for far worse coverage, especially if they are age fifty or older. The standard “reference” plan on the exchanges would cover barely more than half of medical costs, while cost-sharing subsidies for working-class people would be eliminated, and the level of tax credits available to them would be cut, too. The result: the median deductible would jump from the current five hundred dollars to more than six thousand dollars. The annual premium for a sixty-year-old earning fifty thousand dollars in my home town of Athens, Ohio, would triple, to fourteen thousand dollars. In many parts of the country, things would be much worse. (In Anchorage, Alaska, for example, premiums would be thirty-six thousand dollars.) The bill, in other words, promises terrible coverage at unaffordable prices. Millions of people would have to give up insurance, leaving them without protection and the entire individual-insurance market at risk of collapse.
The trade-offs here are indefensible. The bill would take a trillion dollars away from health coverage for the bottom fifty per cent of the population to give a tax cut to the top two per cent. The Center on Budget and Policy Priorities did the math: one consequence of the legislation is that three-quarters of a million people would be thrown off of the Medicaid rolls to give the four hundred highest earners in the country a thirty-three-billion-dollar tax cut. The bill would put thousands of nursing homes, clinics, and hospitals into financial trouble. And for patients it would mean more medical debts, more untreated sickness, and more deaths. A basic test of government is its ability to prevent large-scale harm to its citizens’ health and survival. This bill, and this Administration, are failing that test.
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