If 22 million lose insurance, how many die?

Many commentators have noted that with the election of Trump to the presidency, the Republicans could very well go through with their promise to repeal the Affordable Care Act (ACA), or at least some of its biggest provisions.

As Sarah Kliff at Vox has noted, the Republican Congress already passed a bill—HR 3762—that would (among other things) repeal the major expansion provisions of the ACA (it was, as expected, vetoed by Obama).  As she notes, the Congressional Budget Office has estimated that 22 million individuals would possibly lose coverage as a result of the passage of HR 3762. The  breakdown, by insurance type, is as follows:

Change in covered individuals (millions)
Medicaid -14
Employer-sponsored coverage +10
Non-group coverage -18
Net Effect -22

It’s unclear if in fact the Republicans would actually attempt such a thing knowing that it wouldn’t be vetoed, but it’s worth asking what effect it might have on deaths.  To produce a rough and preliminary estimate, I’ve followed the approach of Dickman et al.,[i] who estimated the number of deaths resulting from states’ failure to expand Medicaid.

Dickman et al. calculated a high and low estimate.  The low estimate was based on a study of the effect of uninsurance by Wilper et al.[ii], which demonstrated a hazard ratio for death of 1.40 for the uninsured as compared to the insured (95% CI = 1.06, 1.84).  Their high estimate was based on the study of Sommers et al.,[iii] which found a relative reduction in all-cause mortality associated with state Medicaid expansion of 6.1%.  Dickman et al. assume a mortality of 320/100,000 for adults aged 20-64.  Based on the study of Sommers et al., they then calculate a “number needed to insure” to prevent one death of 455, and based on the study of Wilper et al., they calculate a number needed to insure of 1,094.  (Of note, a separate study of Sommers and colleagues[iv]—relying on the insurance expansion under Massachusetts health reform—produced an intermediate number needed to insure of 830.  An amicus brief [see pages 5 and 29] submitted by the American Public Health Association and deans, chairs, and faculty of public health relied on this latter number when they asserted that potentially 9,800 lives [8.2 million uninsured/830] could be lost a year if subsidies were withdrawn during the case King v. Burwell).

In any event, dividing the CBO’s 22 million estimated newly uninsured figure by the 455 and 1,094 “number needed to insure” figures drawn from Dickman et al.’s paper produces a potential range of 20,110 – 48,352 excess deaths annually as a result of the repeal in the insurance expansion provisions of the ACA.

Thus, in a piece being published tomorrow in Jacobin, I say that a repeal of the major expansion provisions of the ACA could potentially result in the deaths of 20,000 people a year, assuming 22 million lose insurance.

Of course, those deaths are in addition to the even larger number of deaths resulting from having 29 million uninsured with the ACA in full effect.  Putting these two death tolls together demonstrates why we cannot move backward, but instead must move forward towards a real universal healthcare system (more on that tomorrow).


[i]  Dickman, Sam, David Himmelstein, Danny McCormick, and Steffie Woolhandler. “Opting out of Medicaid expansion: the health and financial impacts.” Health Affairs Blog, January 30 (2014).  Available at: http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts/.

[ii] Wilper, A. P., S. Woolhandler, K. E. Lasser, D. McCormick, D. H. Bor, and D. U. Himmelstein. “Health Insurance and Mortality in US Adults.” Am J Public Health 99, no. 12 (Dec 2009): 2289-95.

[iii] Sommers, Benjamin D., Katherine Baicker, and Arnold M. Epstein. “Mortality and Access to Care among Adults after State Medicaid Expansions.” New England Journal of Medicine 367, no. 11 (2012): 1025-34.

[iv] Sommers, B. D., S. K. Long, and K. Baicker. “Changes in Mortality after Massachusetts Health Care Reform: A Quasi-Experimental Study.” Annals of Internal Medicine 160, no. 9 (2014): 585-93.