As it is currently written, the Senate’s Better Care Reconciliation Act would increase the ranks of the uninsured by 22 million. At least that is the best estimate of the Congressional Budget Office. Many of those rendered uninsured would be older low-income people in some of America’s poorest states, places among those hit hardest by the opioid epidemic, violence, and other public health problems.
By rendering millions of people uninsured and reducing the quality of insurance coverage for millions of others, BCRA would harm millions of people. An estimated 48 percent of the Affordable Care Act’s Medicaid expansion population reports that they have disabilities, chronic illnesses, or are in fair or poor health. Many of these people need care they will not receive if they go uninsured—or for that matter, if they are placed into a cheap but essentially unusable high-deductible plan.
The famed Oregon health insurance experiment identified some of the benefits of insurance that BCRA would snatch away. Men and women who won a lottery to gain Medicaid coverage experienced reduced depression, less trouble managing personal debts, markedly improved self-assessed health, improved management of diabetes and other chronic illnesses, and improved screenings for cancer and other serious diseases. Not everything got measurably better. The OHIE yielded no statistically significant improvement in blood pressure, cholesterol, or blood sugar levels. Still, the benefits found in OHIE match the personal experience of many doctors and nurses I know. So many have seen patients die or experience horrible health outcomes or be financially devastated because they lacked health coverage.
But OHIE involved too few participants for too short a period to rigorously investigate whether Medicaid prevented people from dying. That’s not because researchers were incompetent. Mortality is a rare outcome that arises from many different causes. The consequences of becoming uninsured depend greatly on your ability to access safety-net care from some other source, too, such as a free community clinic or generous public hospital. The survival benefits of insurance are just really hard to pin down.
Conservative polemicists and wonks seize on these uncertainties, seeking to frame the debate as if the public health argument for expanded coverage, particularly for expanded Medicaid, require airtight experimental confirmation of the most difficult outcome to directly study in this way.
This political framing is fairly ridiculous when you step back to think about it. Snatching coverage from millions of people will cause many to experience severe financial problems, declining mental health, and poor management of disabilities and chronic diseases. The human and policy arguments against doing so are hardly nullified if this only hurts people and makes them worse off without actually killing them.
However illogical this framing may be, it is a shrewd polemical gambit. Taking refuge in these specific statistical uncertainties allows conservatives to adopt the pose as dispassionate empiricists who just want to understand the data. Not coincidentally, it allows BCRA supporters to avoid confronting the bill’s brutal distributive realities, diverting attention from the many harms associated with losing health insurance that are more readily studied and thus more solidly grounded.
This framing also allows bill supporters to lambast liberals for uncivil fearmongering and for allegedly making hysterical claims that “MILLIONS WILL DIE!” I haven’t seen people saying that. But it’s easy enough to punch down on social media by finding hysterical-sounding people who exaggerate the numbers, rely on anecdotal data, or misinterpret observational studies.
There’s only—or at least—one problem here. Existing research, for all its flaws, indeed suggests that thousands of Americans will probably die needlessly every year if BCRA is passed. That’s not inflated rhetoric. That’s what any reasonable person would predict based on the available data.
My own favorite study examined the survival benefits of implementing Romneycare in Massachusetts. Other studies compare populations that for one reason or another gained access to expanded Medicaid to populations that did not. Not surprisingly, different studies of different insurance changes applied to different groups find diverse effects. The Massachusetts study suggests that one death is prevented for every 830 people newly insured. Writing at Vox, Ann Crawford-Roberts, Nichole Roxas, and Ichiro Kawachi note that Medicaid coverage thus rivals widely accepted clinical interventions such as screening colonoscopy. If that 1-in-830 finding generalizes BCRA, rendering 22 million people uninsured would imply about 20,000 deaths per year.
Now, existing studies might not fully generalize. Let’s say the Massachusetts study overstates the impact of BCRA by a factor of two. If so, BCRA would still cause around as many annual deaths as firearm homicides. Just as plausibly, the Massachusetts and Oregon studies could actually understate the survival benefits of Medicaid. Both states offer relatively generous medical and social services, including to the uninsured. In Massachusetts, the biggest and clearest mortality effects of Romneycare were found in the lowest-income counties. Medicaid expansion probably matters a lot more in rural West Virginia or Portland, Maine, than it does in southern Massachusetts or Portland, Oregon.
We have strong reason to believe that uninsuring millions of people would cause thousands of them to needlessly die every year. We can debate the magnitude of this effect and how we might measure it. But the burden of proof does not rest with liberals to defend this sensible proposition, nor to prove that the likely harms associated with BCRA will definitely come to pass. Rather, the burden resides with BCRA supporters to show why we can be confident that snatching coverage from low-income people will not bring serious harm. Bill supporters have not come close to meeting this standard.
Writing in the Washington Post, Charles Blahous writes: “Rhetorically assailing lawmakers as heartless brutalizers in the process will only make our national politics more debased and more dangerous.” I believe Blahous has this backward. An unworthy Trump administration and Republican ideologues in Congress have debased American politics by pursuing a shambolic and rushed legislative process to pass a poorly crafted bill we have every reason to believe will cause immense harm. People are rightly angry because BCRA will hurt millions of people.
It may be uncomfortable, but it is neither alarmist nor uncivil to call that out.