Thursday, July 6, 2017

Fear-Mongering About Thousands Dying From Obamacare Repeal Is Unfounded

It doesn't matter who is in the White House. What I do know is that there is no shortage of political grandstanding, much like we see with the current health care debate. A couple of weeks ago, Senator Elizabeth Warren (MA-D) was on the warpath about the repeal of the Affordable Care Act (ACA), saying that a repeal of Obamacare means that "people will die." This idea is based on findings from Congressional Budget Office (CBO) reports on the various renditions of Obamacare repeal. The most recent version, the Senate's version, illustrates that 22 million less people will have coverage (CBO, 2017, p. 4). Left-leaning think-tank Center for American Progress finds that nearly 28,000 people could die in 2026 from such a repeal. The Washington Post puts the estimate at an even-higher 42,000 people. Warren, along with CAP and the Washington Post, believes that this loss in coverage will translate into loss of life. How much basis does such a claim have?
  • First, I have to wonder if Warren bothered to ask herself why the loss in coverage would occur. Under the ACA, the individual mandate required people to either to purchase health insurance or pay a fine. What does the individual mandate have to do with coverage loss? The CBO report that says 22 million less people will have coverage also points out that most of the loss in coverage would be due to the removal of the individual mandate, and people voluntarily choosing to drop their coverage (CBO, 2017, p. 4).  Since these people would willingly make the choice to leave the exchanges, it makes little sense to think of repeal as "killing."
    • I also have to wonder if the CBO's assumption about the power of the individual mandate, and not just because of the CBO's history of overestimating ACA enrollment numbers (see below). The individual mandate penalty was small enough where Jonathan Gruber, the "Obamacare architect," did not find it was impactful at getting people to sign up for health insurance (Gruber et al., 2016).

  • As Charles Blahous brings up in his wonderful analysis on the topic, the ACA is a drag on economic growth (CBO, 2016, p. 20). If there is less economic growth, the nation is collectively poorer. The CBO found that the ACA caused a 1.9 percent decrease in full-time equivalent hours worked (CBO, 2016, p. 18). Since lower income correlates with lower life expectancy (Chetty et al., 2016) and unemployment correlates with health issues, this would mean that the ACA is more likely causing lives to be shorter than longer. Speaking of which.....
  • If repealing the ACA is so awful, then the inverse of the ACA being wonderful for mortality should also be true. This would mean that if a lack of health insurance were killing people, a reduction in the mortality rate would be the optimal metric to show the ACA's success. 
    • Looking at the results from the CDC's WONDER database (see below), we see that the age-adjusted mortality rate has been on a steady decline. What do we see in 2015, which the first year after the major effects of the ACA take effect? The mortality rate increases for the first time this century, not to mention a drop in life expectancy. I understand that looking at one year of data does not constitute a trend, and I also know that other factors drove up the mortality rate (e.g., diabetes, opioid epidemic). But if the ACA were really this wonderful, much-needed overhaul to the health care system, I would have expected a greater decline in the mortality rate or at least a more modest decrease. But we don't even get that. We get more death. We can see what 2016 looked like when the CDC releases the 2016 data, but in the meantime, we work with what we have.
Source: CDC
  • The aforementioned figures from CAP and the Washington Post come from a well-respected study based on the health reform experiment in Massachusetts. However, that same study was clear in explicitly stating "Massachusetts results may not generalize to other states," which the authors acknowledge is most probably due to factors specific to Massachusetts (p. 591). Another study minimized the Massachusetts studying showing that the health care reforms really didn't do all that much to minimize the mortality rate (Kaestner, 2015).
  • The Massachusetts study measures the impact of private insurance. This is significant because, as this Manhattan Institute briefing points out, much of the increase in enrollment since the enactment of the ACA was due to Medicaid. There have been multiple studies on Medicaid effectiveness, but the gold-standard, randomized Oregon Medicaid experiment shows that Medicaid has not had any real effects on physical health (Baicker et al., 2013; also see Courtemanche et al., 2017 for effects of Medicaid). With the effects of Medicaid and how the ACA has disproportionately increased Medicaid enrollment, it is difficult to believe that the ACA is improving physical health quality. Plus, here is this little beaut showing that health care access is not a major detriment for the life expectancy for low-income individuals (Chetty et al., 2016).

So no, Obamacare repeal is not going to kill thousands upon thousands of people. This is more political rhetoric to keep people scared. Plus, equating those who want Obamacare repeal with murderers is as divisive as it is disingenuous.  I haven't been a fan of Obamacare replacement bills (see here and here), but I am even less of a fan of manipulating fears to score political points. No one has a monopoly on compassion, certainly not Senator Warren. I hope we can have a debate on the merits of health care reform instead of ensuing in mudslinging just because you can't withstand having your ideas or policies criticized.

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