June 26, 2017

Gawande, Sommers, and Baicker: Here's how health insurance affects health

Daily Briefing

Expanding health insurance coverage is associated with improvements in health outcomes and a reduction in mortality, and is more cost-effective than some other public policies targeting mortality rates, according an analysis published Wednesday in the New England Journal of Medicine.

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Analysis details

For the analysis, the researchers—Benjamin Sommers, associate professor of health policy and economics at Harvard T.H. Chan School of Public Health and associate professor of medicine at Harvard Medical School; Atul Gawande, director of Ariadne Labs, professor of health policy and management at Harvard Chan School, and surgeon at Brigham and Women’s Hospital; and Katherine Baicker, C. Boyden Gray professor of health economics—sought to determine how health insurance coverage affects health and mortality. The researchers looked at 40 studies published over the past decade, including a few published by the analysis' authors, on the effects of health insurance for nonelderly U.S. residents.

The studies included the Oregon Health Insurance Experiment, a randomized, controlled trial of health insurance coverage, as well as those on Massachusetts' 2006 health care reform, the Affordable Care Act's (ACA) provisions allowing young adults to stay on their parents' plans until age 26, and the ACA's 2014 Medicaid expansion.

The researchers said their findings "provide the best evidence we have for projecting the impact of the ACA or its repeal," but added that the ACA "is a complex law implemented in a highly contentious and uncertain policy environment, and its effects may have been limited by policies in some states that reduced take-up."

Findings

While the effects of health insurance coverage vary depending on the person, setting, and types of plans, the researchers found evidence that expanding insurance coverage provides several benefits, including financial security, improved access to care, lower mortality rates, and better overall health.

For example, the researchers found studies showing that the ACA's Medicaid expansion led to a rise in preventive care visits for testing:

  • Diabetes;
  • HIV; and
  • Hypercholesterolemia.

Similarly, research from the Oregon Health Insurance Experiment showed:

  • A 15-percentage-point rise in cholesterol screening rates; and
  • A 15- to 30-percentage-point increase in breast, cervical, and prostate cancer screening rates.

In terms of health outcomes, the researchers examined several studies that showed people with health insurance coverage report significant improvements in their overall health. For example, researchers found an association between the ACA's: 

  • Dependent-coverage provision and earlier-stage treatment of cervical cancer among young women; and
  • Medicaid expansion and better blood-pressure control among patients at community health centers.

According to the analysis, several studies also suggested there is an association between insurance coverage and mortality rates. The researchers pointed to one study comparing three states with large Medicaid expansions in the early 2000s to neighboring non-expansion states. In the study, researchers found a 6 percent decrease in mortality over five years of follow-up. A subsequent analysis of the study found the largest decreases in deaths for "'health-care-amenable' conditions," such as cancer, heart disease, infections.

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Coverage expansions come at financial costs

While the analysis found evidence that coverage expansions have benefits for health and mortality, they do increase health care spending, raising "key policy questions about how to control costs, how much redistribution across socioeconomic groups is optimal, and how trade-offs among federal, state, local, and private spending should be managed."

However, the researchers wrote, compared with other public policies regarding workplace safety and environmental protections, the findings suggest that coverage expansion is a "more cost-effective" way to reduce mortality rates. For example, they cited an analysis on Medicaid expansion that suggested the program saves lives at a societal cost of $327,000 to $867,000 per saved life. In contrast, other public policies reduce mortality rates at an average of $7.6 million per saved life, the researchers wrote (Harvard T.H. Chan School of Public Health release, 6/21; Sommers et al., New England Journal of Medicine, 6/21; Diamond, "Pulse," Politico, 6/22).

Be prepared for any ACA scenario: Get the Clinical Leader's Resource Guide

Clinical leaders at every level should be preparing for a world in which insurance may be less generous, patients will act more like consumers, hospitals will face tighter margins, and workloads will be heavier and more complex.

To help you and your clinical teams operate in this uncertain time, we've created The Clinical Leader's Resource Guide. Inside you'll find the information and no-regrets strategies needed to support clinical outcomes and financial success in any regulatory environment.

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