Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study
By Benjamin D. Sommers, MD, PhD; Sharon K. Long, PhD; and Katherine Baicker, PhD
Annals of Internal Medicine, May 6, 2014
Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.
Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.
Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.
Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.
Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.
Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention’s Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.
Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.
Limitations: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states.
Conclusion: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care.
From the Discussion
Although we cannot rule out unmeasured confounders, it is challenging to identify factors other than health care reform that might have produced this pattern of results: a declining mortality rate in Massachusetts since 2007 not present in similar counties elsewhere in the country, primarily for health care–amenable causes of death in adults aged 20 to 64 years (but not elderly adults), concentrated among poor and uninsured areas and not explained by changes in poverty or unemployment rates.
Could Obamacare save 24,000 lives a year?
By Harold Pollack
healthinsurancee.org, May 5, 2014
It is a pleasure to read beautifully conducted studies on important subjects. Annals of Internal Medicine published one such study today by Benjamin Sommers, Sharon Long, and Katherine Baicker, three of the most prominent people researching health reform.
Using ten years of mortality data over the period 2000-2010, these authors compare trends in Massachusetts counties to those observed in similar counties in states that did not expand insurance coverage.
Some details are complicated. The final results are admirably clear. Deaths from causes amenable to health care declined by about 4.5 percent in Massachusetts compared with comparison counties. The annual number of deaths declined by an additional 8.2 per 100,000 non-elderly adults in Massachusetts, with larger results for counties with low average incomes and ones that began with lower rates of insurance coverage.
Sommers, Long, and Baicker then perform an intriguing calculation. They estimate that 830 adults would need to gain health insurance coverage to prevent one death per year.
The absolute numbers are also striking. The Congressional Budget Office estimates that ACA will reduce the ranks of uninsured adults by something like 20 million people. I rather heroically extrapolated the authors’ 1/830 estimate to the entire uninsured population across the U.S. This back-of-the-envelope calculation implies that ACA will prevent something like 24,000 deaths every year. That’s almost the number of Americans who die in auto crashes. It’s more than the number who die of AIDS or the number who are murdered every year.
That’s a crude calculation, of course. The authors understandably avoided such a calculation in their paper. One study of Massachusetts can hardly pin down the mortality reduction we can expect from a huge national policy. Still, the findings allow us to glimpse an order of magnitude, which is pretty impressive.
By Don McCanne, MD
This highly credible study of the changes in mortality before and after health care reform was implemented in Massachusetts indicates that one death was prevented for each 830 adults under age 65 gaining health insurance. The deaths that were prevented were concentrated in conditions most likely to be amenable to health care. Health insurance does save lives.
Prior international studies of deaths due to conditions that a well functioning health care system should prevent have shown that the United States has one of the worst rates of preventable mortality. Using the results of this study, it would be easy to conclude that the fact that we have the lowest rate of insurance coverage of all wealthy nations is a major contributor to our high rate of preventable mortality.
Although the authors of this paper state that other confounders cannot be excluded as causes, nevertheless, they write, “it is challenging to identify factors other than health care reform that might have produced this pattern of results.” Conservative critics are already discrediting this study, yet they certainly are not providing any other reasonable explanation for the improved mortality.
Professor Harold Pollack of The University of Chicago has extrapolated the ratio of one life saved for each 830 insured and applied that to the estimated 20 million additional people who will be insured when the Affordable Care Act (ACA) is fully implemented. He estimates that 24,000 lives will be saved.
Using the same extrapolation for the roughly 30 million people who will remain uninsured after full implementation of ACA, we can estimate that about 36,000 people will die each year who would not have had they been insured. Do we really have the gall to passively accept these 36,000 deaths each year just because a few audacious individuals keep telling us that an improved Medicare for all is not politically feasible? Come on! It’s an imperative!