HEALTH -
Mortality Drop Seen to Follow ’06 Health Law
By SABRINA TAVERNISE - MAY 5, 2014
BOSTON — The death rate in Massachusetts dropped significantly after it adopted mandatory health care coverage in 2006, a study released Monday found, offering evidence that the country’s first experiment with universal coverage — and the model for crucial parts of President Obama’s health care law — has saved lives, health economists say.
The study tallied deaths in Massachusetts from 2001 to 2010 and found that the mortality rate — the number of deaths per 100,000 people — fell by about 3 percent in the four years after the law went into effect. The decline was steepest in counties with the highest proportions of poor and previously uninsured people. In contrast, the mortality rate in a control group of counties similar to Massachusetts in other states was largely unchanged.
A national 3 percent decline in mortality among adults under 65 would mean about 17,000 fewer deaths a year.
“It’s big,” said Samuel Preston, a demographer at the University of Pennsylvania and an authority on life expectancy. Professor Preston, who was not involved in the study, called the study “careful and thoughtful,” and said it added to a growing body of evidence that people with health insurance could reap the ultimate benefit — longer life.
Experts said the study, which was published online Monday in the Annals of Internal Medicine, will not settle the long-debated question of whether being insured prolongs life, but it provides the most credible evidence yet that it might. Still, health improvements can take years to surface in mortality data, and some researchers were skeptical of the magnitude and suddenness of the decline.
“Health care is a much more involved process — you don’t just sign up and suddenly get well,” said Joseph Antos, a health economist at the conservative American Enterprise Institute.
Massachusetts is whiter and more affluent than most states, and has more doctors per capita and fewer uninsured people. But researchers said that the state’s health insurance law nevertheless amounted to the best natural experiment the country has had for testing the effects of a major insurance expansion on a large population.
Another study, in Oregon, found that Medicaid, the insurance program for the poor, improved mental health and financial security, but not physical health, and the study was too small to gauge mortality effects.
“This is an important piece of the puzzle,” Katherine Baicker, a professor of health economics at the Harvard School of Public Health, who took part in both studies, said of the Massachusetts one. “Putting the evidence together paints a very strong picture that expanding insurance substantially improves the well-being of people who get it.”
In the waiting rooms of the East Boston Neighborhood Health Center, bustling with a working-class clientele, doctors said much had changed since the state insurance law passed in 2006. People are less likely to put off care out of fear of unaffordable bills, and patients with diabetes can get medication regularly.
Dr. Stelios Maheras, medical director of the emergency department, said some patients used to ask for prices “like at the supermarket.” He recalled one patient who was having chest pains but refused an ambulance because he was afraid of the bill.
“I said, ‘You can’t drive yourself to the hospital — that’s a stress test all on its own!’” Dr. Maheras said. “The attitude has totally changed,” he said, adding that his patients now felt less financially vulnerable and more confident.
In Suffolk County, which includes Boston, the death rate for adults under 65 dropped by about 7 percent from 2005 to 2010, the study’s authors said.
There have been patchy efforts to improve coverage for the poor in states like Arizona, Maine and New York, but Massachusetts is the only state to fully overhaul its health system to cover almost everybody.
But studying the state in isolation was problematic: Was the mortality decline due to expanded insurance coverage, or other factors such as improved eating habits or lower smoking rates? The authors identified 513 counties in 46 other states that were most similar to Massachusetts before reform in demographics and levels of poverty and insurance, then compared their mortality rates with that of Massachusetts. They found that the rate declined 2.9 percent in Massachusetts, but remained flat in counties outside the state.
Researchers also examined death rates for people 65 and over, a population that had been minimally affected by the insurance overhaul. Mortality patterns over time in that age group were the same in Massachusetts and in the control counties.
Dr. Benjamin Sommers, the lead author and a health economist and physician at the Harvard School of Public Health, cautioned that researchers did not have individual data on the 270,000 people who had gained insurance in the state, and could not tell for sure whether it was the expansion that had driven the mortality decline.
Dr. Sommers said that he spent several hours a week advising the Department of Health and Human Services, which pays Harvard for his time, but that it had neither funded nor vetted the study.
Experts said the study was the best attempt yet to isolate the effects of insurance.
David O. Meltzer, a health economist from the University of Chicago, who was not involved in the study, said one of the study’s strengths was its size. It looked at four million people in Massachusetts — the entire population age 20 to 64 — and compared them with more than 44 million people in control counties.
“In the hierarchy of evidence, this ranks way above everything we’ve seen in the past in terms of the effects on mortality,” Professor Meltzer said.
The biggest declines happened for conditions that are more likely to be deadly if not caught early — for example, infections from complications of diabetes, heart attacks and cancer.
Dr. Catherine Silva, a primary care physician at the East Boston health center, said some fatalities might have been prevented by helping people control their high blood pressure and cholesterol, which can increase the risk of heart attacks. She recalled a patient who had hypertension, but dropped out of treatment when she lost insurance, and came back three years later with breast cancer that proved tricky to treat because she had uncontrolled high blood pressure and diabetes.
“That conversation about why did you leave me for three years, that doesn’t happen anymore,” she said.
Researchers have long debated whether having health insurance and better access to medical care saves lives, but it has been hard to construct a study to settle the issue. In 2002, the Institute of Medicine estimated that a lack of health insurance was responsible for 18,000 deaths a year in the United States. But in 2009, a researcher from the University of California found that the survival rate of uninsured people resembled that of insured people.
There will be more evidence, as well, in coming years. The Affordable Care Act is its own sweeping experiment, as only about half the states expanded Medicaid.
“It’s very unfortunate for people living in states not expanding Medicaid,” said Richard Kronick, a health policy official at the Department of Health and Human Services, “but from the point of view of research, it’s a gold mine.”
Correction: May 5, 2014
An earlier version of this article misstated where the decline in the death rate was steepest. It was in counties with the highest proportions of poor and previously uninsured people, not poor and uninsured people.
