H.R. 1628, Better Care Reconciliation Act of 2017

Congressional Budget Office, June 26, 2017

CBO and JCT estimate that enacting the Better Care Reconciliation Act of 2017 would reduce federal deficits by $321 billion over the coming decade and increase the number of people who are uninsured by 22 million in 2026 relative to current law.

Because nongroup insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law.



The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?

By Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.
Annals of Internal Medicine, June 27, 2017


About 28 million Americans are currently uninsured, and millions more could lose coverage under policy reforms proposed in Congress. At the same time, a growing number of policy leaders have called for going beyond the Affordable Care Act to a single-payer national health insurance system that would cover every American. These policy debates lend particular salience to studies evaluating the health effects of insurance coverage. In 2002, an Institute of Medicine review concluded that lack of insurance increases mortality, but several relevant studies have appeared since that time. This article summarizes current evidence concerning the relationship of insurance and mortality. The evidence strengthens confidence in the Institute of Medicine’s conclusion that health insurance saves lives: The odds of dying among the insured relative to the uninsured is 0.71 to 0.97.

From the Discussion

The evidence accumulated since the publication of the IOM’s report in 2002 supports and strengthens its conclusion that health insurance reduces mortality. Several newer observational and quasi-experimental studies have found that uninsurance shortens survival, and a few with null results used confounded or questionable adjustments for baseline health. The results of the only recent RCT, although far from definitive, are consistent with the positive findings from cohort and quasi-experimental analyses.

Several factors complicate efforts to determine whether uninsurance increases mortality. Randomly assigning people to uninsurance is usually unethical, and quasi-experimental analyses rest on unverifiable assumptions. Deaths are rare and mortality effects may be delayed, mandating large studies with long follow-up. Many people cycle into and out of coverage, diluting the effects of insurance. And statistical adjustments for baseline health usually rely on participants’ self-reports, which may be influenced by coverage. Hence, such adjustments may under- or overadjust for differences between insured and uninsured persons.

Our focus on mortality should not obscure other well-established benefits of health insurance: improved self-rated health, financial protection, and reduced likelihood of depression. Insurance is the gateway to medical care, whose aim is not just saving lives but also relieving human suffering.

Overall, the case for coverage is strong. Even skeptics who suggest that insurance doesn’t improve outcomes seem to vote differently with their feet. As one prominent economist (Paul Krugman) recently asked, “How many of the people who write such things… choose to just not bother getting their healthcare?”


Although the precise numbers are somewhat elusive, this comprehensive review of existing studies confirms that health insurance reduces mortality. The Congressional Budget Office concludes that another 22 million people will be uninsured compared to current law if the Better Care Reconciliation Act were enacted and implemented. If this Republican repeal and replace bill becomes law, more people will die as a result.

Obviously the reduction in mortality is not the sole function of insurance. As the authors of this Annals of Internal Medicine article state, “Insurance is the gateway to medical care, whose aim is not just saving lives but also relieving human suffering.” Importantly, it also provides financial protection, which otherwise would deteriorate under the Republican proposal. (The full landmark article by Steffie Woolhandler and David Himmelstein is available for free at the link above.)

If there ever was a time to intensify the policy debate, this is it. The repeal and replace movement became popular because of the acknowledged deficiencies of the Affordable Care Act – leaving millions uninsured, millions more with inadequate financial protection, perpetuation of a dysfunctional insurance market that takes away choices, while failing to remedy the profound administrative waste that uniquely characterizes the U.S. health care financing system.

The Republicans have done us a favor by showing us that replacement policies that assume perpetuation of our fragmented infrastructure of private plans and public programs cannot remedy the profound deficiencies in our system. With six years of debate, the policies proposed do not correct the fundamental flaws in the financing infrastructure and actually would only compound the problems, including increasing mortality caused by being uninsured.

It is not as if we do not understand optimal health policy. We do. A well designed single payer national health program – an improved Medicare for all – would ensure that all of us would have the essential health care services that we need in a system that would be affordable for each of us. And, oh yes, nobody would die simply because they were uninsured.

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