About that 10,000

Larry Summers has been making the rounds of TV and op-ed pages claiming that the tax bill, by repealing the individual mandate for Obamacare, will cause 10,000 additional deaths a year. The reasoning is pretty simple: once people no longer are forced to buy insurance, the most healthy people will decide not to, driving up premiums (since those remaining in the risk pool are higher risk) and causing more people to leave, which causes premiums to rise still higher, which causes…the “insurance death spiral.” Eventually, the subsidies will probably be sufficient to keep some people in the exchanges, but in the meantime, you have a much higher uninsured rate than you did before, which Summers says will cause 10,000 more medically preventable deaths annually.

This would be great reasoning, except…we just reduced the uninsured rate very considerably, and got a significantly higher population-wide mortality rate as a result. The uninsured rate dropped from 13.3 percent in 2013 to 9.1 percent in 2015, thanks to Obamacare. At the same time, age-adjusted, all-cause mortality for 25-64 year olds (the population affected by the ACA),rose 7.3 per 100,000.

Of that 7.3, 4.5 was increases in drug overdoses due to the opioid crisis.

The uninsured rate among nonelderly adults, the population most directly affected by Obamacare, dropped from 20.5% in 2013 to 12.2% in 2016, a 40% decline. At the same time, the age-adjusted all-cause mortality rate for 25-64 year olds (again, the population affected by the ACA) rose by 16.1 per 100,000, a 5% increase. Of that 16.1, 10.7 was drug-related.

You’d think the Republicans could get somebody on TV to say this stuff. There’s essentially nobody in public who will say that health care and health insurance has minimal (and sometimes negative) influence on mortality, even the party that goes around trying to get elected by repealing health insurance expansions.

Apart from the Opioid-ACA connection, I don’t think in general that insurance is actually killing people. But, especially given that the people who are most likely to lose insurance are those who are choosing not to buy it, I’d be pretty sure that Summers’s estimate is way off. There is one way, though, in which he might be right.

If the exchanges fall apart or are available only to those with particularly large subsidies, there will be a lot of pressure (financial and possibly social) for individuals to hide income to qualify for Medicaid or for more subsidies to purchase insurance. There are different ways of doing this, but one way is to actually stop making as much or any money, or to get divorced (or not get married in the first place). Insurance may not have much positive association with mortality for non-elderly adults, but employment and marriage definitely do. So by creating a marginal tax “cliff“- where working a bit more or getting married makes you lose your insurance, the tax bill might end up killing people after all.

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