How does Obamacare save lives?

  • So I'm having this argument. I see people on the news testify that if Obamacare is repealed, then they won't be able to pay for their preexisting condition and will die.

    However, the opponents argue that Medicaid will foot the bill and treatment is never denied, even in the days before Obamacare.

    Which is true? Does Obamacare cover more than Medicaid? It's hard to find sources on this because I feel like every article somehow dodges this question.

    EDIT: Hey guys, the answers here are all insightful. Don't forget to play nice. I'm assuming we all have similar moral compasses on what is right and what is wrong. None of us believe that people deserve to die because of health issues or poverty, but it can be easy to misconstrue each other when we talk about differing plans. Regarding the original question, some stats in the answers provided have shown that there is a gap left open by Medicaid, something I didn't know existed.

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  • ohwilleke

    ohwilleke Correct answer

    5 years ago

    In a nutshell, the income threshold necessary to qualify for Medicaid (the poverty line prior to Medicaid expansion) is lower than the amount of income needed to pay for the medical care that Medicaid provides to people who are eligible for it.

    For example, if you need dialysis to stay healthy (which is not ER room care), it costs more than $70,000 per year. And, if you need this care and don't get this care, you die in a matter of weeks or months.

    This is one example and actually not a great one in terms of health care access because there is actually a special end stage renal disease program in Medicare that covers this particular treatment if you are uninsured. But, there are many conditions that have the same cost/risk profile as end stage renal disease, in that they require long term, regular, expensive care to avoid a dramatic shortening of your life, for which there is no special coverage. For example, there is no counterpart to Medicare if you have ALS or advanced stage MS.

    If you do not qualify for Medicaid and do not have health insurance at the time you need health care, possibly because you cannot afford health insurance at the market rate, which is on average $16,351 per year for a family of four, then the only health care you can insist on having provided to you is ER care necessary to stabilize your condition pursuant to EMTALA (the Emergency Medical Treatment and Labor Act). And, many people who do not qualify for Medicaid at the poverty line cutoff level cannot afford to buy market rate health insurance.

    But, care that stabilizes your condition from an ER is not sufficient to keep people alive. Therefore, some people who lose Medicaid will die from lack of access to health care.

    Basically, pre-ACA, if you are at risk of dying for lack of medical care, you have to quit any job that pays you above the poverty line even if you could earn more but not enough to pay for health insurance. Lots of working class people with serious health problems did this prior to the ACA.

    Moreover, a study looking at medical records for 30,000 people as a random sample compared death rates before and after Medicaid expansion (to 138% of the poverty line) and expanded private health insurance covers under the ACA due to mandates and credits (which apply up to 400% of the poverty line), and demonstrated statistically that 50,000 lives were saved by the ACA over a three year time period. The Washington Post, which reviewed the data found that this was an underestimate and that 87,000 deaths avoided was a more accurate figure. In addition, $12 million of costs were saved and about 1.3 million people who would have been harmed from lack of medical care without dying avoided that harm.

    Presumably, death rates would rise again if it was contracted and there were more uninsured individuals.

    About two-thirds of the lives saved involved death arising from sepsis associated with pressure ulcers and adverse drug events according to the Washington Post account.

    For a family of four in 2016 the relevant ACA income cutoffs were as follows:

    100% of poverty line: $24,300

    138% of poverty line: $33,534

    400% of poverty line: $97,200

    (tax credits can be applied in advance rather than when a return is filed if your income is $60,750 or more which is 250% of the poverty line).

    This was causally related to the fact that:

    As of the end of 2015, the number of uninsured nonelderly Americans stood at 28.5 million, a decrease of nearly 13 million since 2013.

    Note that this data implies that roughly 1 life is saved per year per 1000 additional people with health insurance.

    So couldn't we expand medicaid instead of using obamacare? I know Obamacare is just insurance, but the end result is the same and the cost of administering treatment is the same, so even bother with Obamacare?

    We could enact Medicaid for all, or Medicaid up to 400% of the poverty line, or would could enact Medicare for all. The ACA chose to subsidize private health insurance between 138% and 400% of the poverty line in lieu of doing that, but there are multiple approaches that could have worked.

    This is a good post. I can't think of any benefits there are to making health insurance more accessible instead of just health care. It would probably just be better to expand medicaid then IMO

    Expanding Medicaid very much isn't really viable, however, because it relies on paying providers far below market rates for services rendered (much less than the VA or Medicare or private insurance pay), and assumes that providers subsidize their Medicaid losses with profits from other kinds of care. Therefore, many providers don't take Medicaid and there are long waiting periods. Medicaid would be 50% more expensive if it paid market rates.,%22sort%22:%22asc%22%7D

    @ScriptKitty the *cost* of adninstering the treatment is largely irrelevant in the USA, because the Healthcare Industry is what its name says: it's a *profit-making industry* (and it includes the health insurance companies). But unless somebody can figure out how to persuade turkeys to vote for Thanksgiving, there isn't much chance of dismantling that *industry* and turning it into a *public service,* which is the way universal health care is run in other countries where it is funded (much more cheaply) from general taxation.

    ... and of course a Healthcare Industry looks for the most profitable conditions to treat, even if it has to invent them. Convince me that the basic reason why "more than 20% of US children suffer at some stage from a debilitating mental illness or disorder" ( isn't simply that parents are a soft touch for paying any amount of money you want to ask for, if they think something is "wrong" with their kids and you can fix it!

    @ScriptKitty 'expanding medicaid' is essentially the 'single payer' model. We *could* have done that but we didn't for a variety of reasons. There was a 'public option' along those lines in the original ACA proposal, however. (It was removed.).

    @alephzero there's lots of reasons, and I'm not about to convince you, however, *one* of the reasons is that we have a much better understanding of mental health year after year. We're still a long way from fully understanding the brain but compared to even 40 years go, we know so much more.

    @blip You’re absolutely right that we understand more, and some portion of the increased diagnosis of these issues is due to increased understanding and awareness, but we’d be fools not to suspect that at least some other portion of that increase is due to the predatory practices of a near-fraudulent industry.

    @KRyan we agree on that point! There's definitely motivations from the for-profit industries involved.

    @alphazero While health insurance company profits, marketing and gate-keeping costs do add to the cost of health care, by far the main reason that U.S. pays more for healthcare than any other country is that providers of all sorts from nurses and doctors to hospitals to drug and device sellers are all paid much more (often twice as much) as those in other comparably affluent countries for the same services. A fragmented health insurance market and a ban on price control by Medicare largely drives this reality.

    @blip There is no doubt that the U.S. overall pays much more to providers for fewer services from providers. and US pay to medical professionals is very high even in cases when it isn't the absolute highest. For example in this study U.S. GPs and nurses were the best paid in the world and specialists were third.

    @ohwilleke I agree we pay well, but the greater costs really have to do with the broader for-profit system. I'm just wary of jumping on the actual doctors as being the problem, as they really aren't.

    @blip Pay for doctors and nurses is a real part of the problem. Pay for other providers is also part of the problem. Pay for providers generally is a bigger part of the problem in magnitude than profits and administrative costs at insurance companies, although that is also part of the problem. People are reluctant to focus on doctors for a variety of reasons, but the reality is that their unusually high pay, in part due to supply shortages because medical school capacity has not grown and in part due to market failure, is an important driver of higher medical costs in the U.S.

    @ohwilleke it's a matter of opinion, I suppose, but in terms of the total percentage, the actual doctor salaries are just a drop in the bucket. The hospital and incidental costs are so much higher (and, not surprisingly, seemingly so much more arbitrary from hospital to hospital).

    @blip Doctors are 20% of the total directly and an additional percentage indirectly, the largest component of cost after hospitals (which includes some indirect physician costs). Other medical professionals and dentists included brings it to 27%.

    A tangent to this discussion (for me at least), is the following question: How does it make sense to have health insurance attached to who your employer is or isn't? I had a job with a small company (~20 people) where I was close to the owner, and saw him struggle to find something affordable to the company and half-decent for employees. After jumping ship to a large corporation, I've now got pretty dang good medical benefits. I'm same person, same family, same job duties, superior benefits. Doesn't make sense to me.

    @eflat Strictly a matter of historical accident, worthy of a separate question. Employer provided health care basically dates to union driven concessions in the 1950s and relates back to Prussian ideas about the role of a manufacturing employer vis-a-vis employees.

    @ohwilleke Actually it started in the 1940s. There were wage controls in place during World War II, so employers tried to find other ways to entice people to come work for them.

    " ... pre-ACA, if you are at risk of dying for lack of medical care, you have to quit any job that pays you above the poverty line ... lots of working class people with serious health problems did this prior to the ACA." I'd like to see a citation for this, especially because labor force participation has *decreased* significantly since 2008.

    The linked study -- that purportedly shows that Obamacare saved 50,000+ lives -- says that improvements in hosptial safety / quality procedures are responsible for the decrease in deaths. This is a significant achievement, but I don't see how this relates to the ACA (and I didn't see that mentioned anywhere in the report).

    @David it was a very common situation in the past decade or so. Those people working at Home Depot? They don't like that job. It doesn't pay well. But for a lot of contractors, it was the only way to get insurance. People *have* gotten divorce so that one spouse could qualify for medicaid. Having to depend entirely on employers for health insurance is a burden for the consumer and increasingly, a burden for the employer.

    @blip I'd still like to see some hard data. I do agree that employer-provided insurance is a problem; however, this started as a way for employers to attract employees during WWII when wage controls were in place i.e. *because of government regulation*.

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