Will the Uninsured Become Healthier Once They Receive Health Care Coverage?

David OrentlicherThe Affordable Care Act might not bend the cost curve or improve the quality of health care, but it will save thousands of lives, as millions of uninsured persons receive the health care they need.

At least that’s the conventional wisdom.

But while observers assume that ACA will improve the health of the uninsured, the link between health insurance and health is not as clear as one may think. Partly because other factors have a bigger impact on health than does health care and partly because the uninsured can rely on the health care safety net, ACA’s impact on the health of the previously uninsured may be less than expected.

To be sure, the insured are healthier than the uninsured. According to one study, the uninsured have a mortality rate 40% higher than that of the insured. However, there are other differences between the insured and the uninsured besides their insurance status, including education, wealth, and other measures of socioeconomic status.

How much does health insurance improve the health of the uninsured? The empirical literature sends a mixed message. On one hand is an important Medicaid study. Researchers compared three states that had expanded their Medicaid programs to include childless adults with neighboring states that were similar demographically but had not undertaken similar expansions of their Medicaid programs.

In the aggregate, the states with the expansions saw significant reductions in mortality rates compared to the neighboring states.

On the other hand is another important Medicaid study. After Oregon added a limited number of slots to its Medicaid program and assigned the new slots by lottery, it effectively created a randomized controlled study of the benefits of Medicaid coverage. When researchers analyzed data from the first two years of the expansion, they found that the coverage resulted in greater utilization of the health care system.

However, coverage did not lead to a reduction in levels of hypertension, high cholesterol or diabetes.

Also, in a nationwide study of people age 50-61, researchers looked at the study subjects’ access to health care and their health outcomes for the next 18 years. As expected, insured individuals used more health care resources than did uninsured people.

However, there was no evidence that being insured lowered the risk of death 12-14 years into the study, and only mild evidence of a mortality benefit at 16-18 years.

All of this is not to say that health care does not matter. Rather, it is not clear how much more ACA will do for the health of the previously uninsured than did the pre-ACA safety net. The safety net is porous, but it provides important benefits to the uninsured. In addition, ACA’s impact will be limited because it put most of its money on treatment, and that was not a wise bet.

It has long been clear that public health interventions do more to promote health than do treatments of disease. It also may be true that health care coverage is a necessary but not sufficient factor in improving a person’s health. The uninsured face many barriers to receiving good health care, and they often may need other kinds of assistance to ensure that they realize the full benefits of health care coverage.

In the end, the benefits of ACA may lie more in their contribution to economic health than physical health. Support for ACA was driven in large part by concerns about the extent to which health care costs were overwhelming family budgets and forcing Americans into bankruptcy.

ACA will greatly reduce the financial burden from health care needs, and this is very important.

David Orentlicher, MD, JD is Samuel R. Rosen Professor at Indiana University’s  Robert H . McKinney School of law and adjunct professor of medicine at Indiana University School of Medicine. This piece originally appeared on his personal blog, orentlicher.tumblr.com

12 replies »

  1. R Gray – I totally agree with you. Giving a person an insurance card does nothing to improve his everyday lifestyle, income or habits. Yes it may give him some preventative advantages, but if he eats poorly, smokes, doesn’t exercise, etc, his health will remain the same despite having insurance.

  2. Of course having health insurance would not show decreases in diabetes,hypertension &high LDL if one does not make life style habit changes.The most qualified MDs could advise you,but without your compliance,your health probably won’t improve.

  3. “Primary medical care is free in Canada because all Canadians pay higher taxes.”

    Actually Bob they tax the wealthier more (less distance between 1% and 99%) than here, and their health costs are about half.

    We looked at moving back to Canada several years ago and did an analysis on income tax. About the same as here, but they do have a Federal HST (VAT) and other stuff costs more. Provincial sales tax about what we pay here in state sales – 7%.

    It’s not as bad as you think, or at least as bad as the 1% would like you to think.

  4. Answer to Jeff:

    Primary medical care is free in Canada because all Canadians pay higher taxes.

    If America enacted enough sales taxes to make primary care free, a Big Mac would cost $7 instead of $4.

    Might not be a bad trade-off!!

  5. How can people be healthy when they’re forced to spend all their food money on insurance?

    Low-income Canadians pay nothing for medical care. 100% free. Why not the same in the U.S.?

  6. Some of my thoughts on socioeconomic health factors here:


    “[W]e focus too much on technological and process improvements at our policy peril. Toxic organizational dynamics and socioeconomic considerations (the latter addressed at cogent length in The American Health Care Paradox) are equally important, IMO.”

  7. “In the end, the benefits of ACA may lie more in their contribution to economic health than physical health.”

    I doubt the above assertion.

    “I am ignoring premium costs in the above arguments…just talking about OOP expenses.”

    I agree with Doc Palmer on proving economic savings when the OOP costs are so high. Given that insurance will kick in for a major illness expense also may not protect income. Major illnesses also may mean loss of the ability to earn income or keep your job, which will prevent the payment of premiums to keep coverage. People in lower incomes notoriously have little cushion savings.

  8. I’m not so sure re financial burden reduction. When folks are locked into actuarial values of 60% as in the bronze plans–and there is now talk of a copper plan with 50% AV–this means that on average they will have to pay 40-50% of covered services out of pocket in the form of co’s and deductibles. The problem is that this is not always upfront money where they have a choice. It is often dough that is demanded during a course of treatment, where to refuse to pay a co could be medically dangerous.

    The ultimate result is that some patients may pay more for health care with insurance than they would without. Skimpy dental insurance causes 100,000 people with insurance to spend more for their teeth than would be spent by the same number of folks without insurance because the insurance locks them into further OOP payments for bridges, crowns, etc.

    I am ignoring premium costs in the above arguments…just talking about OOP expenses.

  9. Perry is completely right.

    Health insurance does not equal health care which does not equal health. The first is a financing mechanism for the second, which is a service that is available even without the first. The last is a state of being that does not require either of the first two, even though they can, at times, provide support for it.

    The American pursuit of health, bizarrely and stupidly, conflates these three things and people who literally do not know any better use the three terms interchangeably. The most important drivers of good health are education, income, personal habits, sanitation, and a range of public health initiatives that helped to tame infectious diseases and injuries.

    Instead of engaging in an orgy of medical care consumption, we should be asking Americans to see how much they can do for themselves, independent of the health insurance and medical care markets, to see how little they can use so that we can actually optimize the size of the medical care system. Instead of constantly complaining about about how big the military is, how come we don’t complain about how big, intrusive, arrogant, and deceptive the medical care system is? For all the money we pour into it, we get a terrible ROI.

  10. This is the way I see it:
    Having health insurance is not the same as having health, or even health care.
    How much the ACA will do is yet to be seen.
    The second issue is, once you have access to health care, will you be able to afford it? Again, I think this will remain unanswered in the immediate future.