A shocking number of people seem to be under the impression that expanding health coverage would not actually do anything to improve the United States’ dismal health outcomes relative to other nations. In order to correct this (stunningly obvious) fallacy, it is necessary to make a brief survey of the evidence. All sources are listed at the end.
Uninsurance’s Impact on Health Outcomes
There is substantial evidence that lack of health insurance is associated with increased mortality and poor health outcomes. To begin with, a landmark 2002 report from the Institute of Medicine (now the National Academy of Medicine) found that “working-age Americans without health insurance are more likely to receive too little medical care and receive it too late; be sicker and die sooner; and receive poorer care when they are in the hospital, even for acute situations like a motor vehicle crash.” Similarly, a 2009 study from Harvard Medical School, published in the American Journal of Public Health, found the following:
Lack of health insurance is associated with as many as 44,789 deaths per year in the United States, more than those caused by kidney disease (n = 42,868).
These findings were revisited in a 2017 paper, published in the Annals of Internal Medicine, which found that “health insurance saves lives: The odds of dying among the insured relative to the uninsured is 0.71 to 0.97.” Among the major reasons for this was that “lack of coverage is associated with lower use of recommended preventive services.”
This finding (i.e. that uninsurance is associated with less use of preventative care) is supported by other research. For example, a 2019 report from the Kaiser Family Foundation found that “people without health insurance are more likely to skip preventive services and report that they do not have a regular source of health care.” From this, we can clearly see that a lack of insurance is associated with higher mortality rates, caused partly by a reduced use of primary and preventative care.
Expanding Coverage Improves Health Outcomes
The best evidence on what happens when we provide previously-uninsured people with insurance comes from the Affordable Care Act, particularly the associated Medicaid expansion. A 2020 literature review from the Kaiser Family Foundation looked at over four-hundred studies, with the following results relating to access and outcomes:
Most research demonstrates that Medicaid expansion has improved access to care, utilization of services, the affordability of care, and financial security among the low-income population. Studies show improved self-reported health following expansion and an association between expansion and certain positive health outcomes.
An analysis of specific recent studies validates these results. A 2019 paper from the National Bureau of Economic Research found that the ACA “led to increased coverage in the two years following treatment and that this additional coverage reduced mortality among middle-aged adults over the same time period.” The authors note that these results “provide the first experimental evidence that health insurance reduces mortality.”
A 2021 study, also from the NBER, examined the effects of Medicaid expansion on health outcomes, finding “significant reductions in mortality in states that opted to expand relative to non-expanders.” Similarly, a 2020 paper in the Journal of Health Economics found “a reduction in all-cause mortality in ages 20 to 64 equaling 11.36 deaths per 100,000 individuals, a 3.6 percent decrease.” The authors continue:
This estimate is largely driven by reductions in mortality in counties with higher pre-expansion uninsured rates and for causes of death likely to be influenced by access to healthcare. A cost-benefit analysis shows that the improvement in welfare due to mortality responses may offset the entire net-of-transfers expenditure associated with the expansion.
Focusing on infant mortality, a 2018 paper in the American Journal of Public Health found that the infant mortality rate fell in expansion states, while actually rising in non-expansion states:
Mean infant mortality rate in non–Medicaid expansion states rose (6.4 to 6.5) from 2014 to 2016 but declined in Medicaid expansion states (5.9 to 5.6). […] Infant mortality rate decline was greater in Medicaid expansion states, with greater declines among African American infants.
A 2020 paper in JAMA found that “Medicaid expansion was associated with a decreased hazard of mortality among patients with newly diagnosed breast, colorectal, and lung cancer.” Similarly, a 2019 paper in JAMA found that “Medicaid expansion was associated with lower cardiovascular mortality and may be an important consideration for states debating expansion of Medicaid eligibility.”
This trend holds true when it comes to mental health outcomes. A 2018 paper in the journal Psychiatric Services found that “Medicaid expansion was associated with improved access to care and medication among persons with depression, even in areas with relative shortages of mental health professionals.” Similarly, a 2018 study in the Journal of General Internal Medicine found the following:
Medicaid expansion was associated with substantial improvements in mental health and access to care among low-income adults with chronic conditions. These positive trends are likely to be reversed if Medicaid expansion is repealed.
All-in-all, there is substantial evidence that Medicaid expansion reduced various kinds of mortality, increased access to care, and substantially improved mental health. This indicates that access to healthcare is a major cause of improved health outcomes, and that achieving universal coverage would likely improve things further. With that said, let’s move on to looking at financial outcomes.
Medical Bankruptcy and Coverage Expansion
Medical costs appear to be a major contributing factor to bankruptcy in the United States. A 2019 paper in the American Journal of Public Health found that medical bills continue to be a common contributor to bankruptcies in the United States, even despite the Affordable Care Act:
The share of debtors reporting a medical contributor before the ACA’s January 1, 2014 implementation (65.5%) and after implementation (67.5%) was similar. […] The responses regarding individual items in the current survey are also similar to those in 2007, when 57.1% of debtors cited medical bills as contributors to their bankruptcy and 40.3% cited income loss due to illness.
However, while the proportion of bankruptcies with a medical cause was similar before and after the ACA, it nevertheless reduced the number of bankruptcies rather substantially. A 2019 paper from the Minneapolis Fed found that “75,000–125,000 bankruptcies were prevented by the ACA Medicaid expansion between 2014–2016 among low-income individuals, an approximate 6–8% decrease in the bankruptcy rate.” Similarly, a 2017 article from Consumer Reports notes that bankruptcy claims in the US declined precipitously after the ACA went info affect, with the expansion of Medicaid in particular likely playing a major role.
Poverty, Financial Distress, and Medicaid
In addition to bankruptcy, generalized financial distress (and the negative effects that come along with it) also fell dramatically after Medicaid expansion. The aforementioned 2020 literature review from the Kaiser Family foundation found that “Medicaid expansion improves the affordability of health care.” They continue:
Medicaid expansion significantly reduced the percentage of people with medical debt, reduced the average size of medical debt, and reduced the probability of having one or more medical bills go to collections in the past 6 months.
Medicaid appears appears to have a general anti-poverty impact as well. For example, a 2019 paper in the American Journal of Public Health found that food insecurity fell after the ACA’s Medicaid expansion, suggesting that “health insurance provision has spillover effects that reduce other dimensions of poverty.” They continue:
Providing free or low-cost health insurance coverage may free up household funds, reducing food insecurity and improving this important social determinant of health.
Similarly, a 2019 paper in Health Affairs found that “Medicaid expansion caused a significant reduction in the poverty rate.” Interestingly, Medicaid’s antipoverty impact “grew over the past decade independent of expansion, by shielding beneficiaries from growing out-of-pocket spending.” The authors explain:
Out-of-pocket spending on health care pushed over 10.5 million Americans into poverty in 2016. Medicaid helps offset this risk by providing medical coverage to millions of poor and near-poor children and adults and thereby constraining out-of-pocket medical spending.
All-in-all, the evidence is clear that the expansion of medical coverage reduces financial distress, poverty, food insecurity, and medical bankruptcies, as well as the psychological and physical health effects which result from all of these things.
Social Outcomes (Crime, Drugs, Etc.)
In addition to its clear beneficial impact on health and financial wellbeing, expanded health coverage also has a positive impact on various social outcomes. For example, a 2020 study in the journal Health Economics examined the impact of Medicaid expansion on crime rates, finding:
Medicaid expansion was negatively associated with burglary, vehicle theft, homicide, robbery, and assault. These crime‐reduction spillover effects represent an important offset to the government’s cost burden for the ACA Medicaid expansion.
This follows several earlier studies, which found similar results. A 2017 paper in the Journal of Public Economics found that “Medicaid expansions led to an economically meaningful reduction in the rates of robbery, aggravated assault and larceny theft.” In addition, a 2020 paper in the Journal of Policy Analysis and Management found “states that expanded Medicaid have experienced a 5.3 percent reduction in annual reported violent crime rates relative to nonexpansion states,” amounting to “an annual cost savings of approximately $4 billion.”
Evidence also suggests that Medicaid expansion may have reduced overdose deaths. A 2018 study in the Journal of General Internal Medicine found the following:
Drug overdose mortality rates rose less sharply in three states that expanded Medicaid in the early 2000s as compared to states that did not. These findings suggest that Medicaid expansions were unlikely to have contributed to the subsequent rise in drug overdose deaths and may, in fact, have been protective.
While it is commonly claimed that Medicaid expansion contributed to the growth of the opioid crisis, the evidence for this claim is remarkably weak. In addition to the aforementioned study (which touches on this topic), a 2017 article in Health Affairs gives at least three reasons why Medicaid expansion is unlikely to have contributed to the epidemic:
First, trends in opioid deaths nationally and by Medicaid expansion status predate the ACA. Second, counties with the largest coverage gains actually experienced smaller increases in drug-related mortality than counties with smaller coverage gains. Third, the fact that Medicaid recipients fill more opioid prescriptions than non-recipients largely reflects greater levels of disability and chronic illness in the populations that Medicaid serves.
All-in-all, it seems clear that Medicaid expansion significantly reduced crime rates, without any substantial negative effects on drug abuse. While some have claimed a relationship between Medicaid expansion and the opioid crisis, there is very little evidence for this claim.
Hopefully this brief discussion of the evidence makes it clear that the expansion of medical coverage is good for people’s health (both physical and mental), as well as various economic and social outcomes. If we want to improve health, reduce financial burden, and improve social outcomes as a whole, insuring universal coverage (preferably via a single-payer system) is essential.
- Health System Tracker (KFF) | How Does the Quality of the US Healthcare System Compare to Other Countries?
- National Academy of Medicine (Institute of Medicine) | Care Without Coverage: Too Little, Too Late
- Annals of Internal Medicine | The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?
- Kaiser Family Foundation | How Does Lack of Insurance Affect Access to Care?
- Kaiser Family Foundation | The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review
- National Bureau of Economic Research | Health Insurance and Mortality: Experimental Evidence From Taxpayer Outreach
- National Bureau of Economic Research | Medicaid and Mortality: New Evidence From Linked Survey and Administrative Data
- Journal of Health Economics | Did the ACA Medicaid Expansion Save Lives?
- American Journal of Public Health | Medicaid Expansion and Infant Mortality in the United States
- JAMA Network Open | Medicaid Expansion and Mortality Among Patients With Breast, Lung, and Colorectal Cancer
- JAMA Cardiology | Association of Medicaid Expansion With Cardiovascular Mortality
- Psychiatric Services | Effect of Medicaid Expansion on Health Insurance Coverage and Access to Care Among Adults With Depression
- Journal of General Internal Medicine | Medicaid Expansion, Mental Health, and Access to Care among Childless Adults with and without Chronic Conditions
- American Journal of Public Health | Medical Bankruptcy: Still Common Despite the Affordable Care Act
- Minneapolis Fed | What is the Impact of a Medicaid Expansion on the Bankruptcy Rate? Evidence from the ACA
- Consumer Reports | How the Affordable Care Act Drove Down Personal Bankruptcy
- American Journal of Public Health | Effect of the Affordable Care Act’s Medicaid Expansions on Food Security, 2010–2016
- Health Affairs | Antipoverty Impact of Medicaid Growing With State Expansions Over Time
- Health Economics | The Effect of Health Insurance on Crime: Evidence From the Affordable Care Act Medicaid Expansion
- Journal of Public Economics | The Effect Medicaid Expansion on Crime Reduction: Evidence From HIFA-waiver Expansions
- Journal of Policy Analysis and Management | Access to Healthcare and Criminal Behavior: Evidence From the ACA Medicaid Expansions
- Journal of General Internal Medicine | Early Medicaid Expansions and Drug Overdose Mortality in the US: A Quasi-Experimental Analysis
- Health Affairs | Did Medicaid Expansion Cause the Opioid Epidemic? There’s Little Evidence That It Did