There recently has been a flurry of declarations by Democratic politicians, scholars, and pundits that the bill replacing of Obamacare is literally deadly. This is a pretty potent argument, and an especially shocking one, as it essentially accuses Republicans to willfully kill Americans.
I want to stop on one of these statements. In January, Sen. Bernie Sanders said on Twitter that the Obamacare replacement would kill 36,000 people. He was promptly rebuked by the Washington Post, which considered his declaration nonsensical, partially because the details of the Obamacare repeal law were not known at the time. Now that the bills are on the table, and given the additional similar declarations by other Democrats, I figured it would useful to re-check that claim today, and see if it is still worthy of a rebuttal.
In short, the overall direction of that statement may be true, but the number truly is baseless. There is no proper study to back up that precise number. Indeed, no study provided a precise answer as to how many deaths would result from a repeal law. Unsurprisingly, Democrats have put forward wildly different numbers than just 36,000.
The numbers put forward by Democrats are generally recycled from two health policy studies:
- The first one looks at how the mortality rate evolved in states that expanded Medicaid in the early 2000s vis-à-vis the ones who didn’t. They found that it saved one life for every 455 newly-insured people; extrapolating that to 20 million insurance losses, you find 44,000 deaths annually.
- The second one looks at how the rate evolved in Massachusetts after the passage of ‘Romneycare’, which was an Obamacare-like system in that state. They found that it saved one life for every 830 newly-insured adults. This translates to 24,000 or 36,000 deaths nationally if you estimate, respectively, that the law will make 20 or 30 million Americans lose health insurance.
The 36,000 number that Sanders quoted came probably from the conclusion of the second study, as well as an extrapolation based on 30 million health insurance losses. The Washington Post was right when asserting that Sanders couldn’t know how many people would lose health insurance because of the Obamacare repeal, indeed, he was off by 5 to 8 millions. So, even if we apply Sanders’ methodology to the death question, we would find something in the range of 30,000 people.
But even applying Sanders’ methodology is problematic. Translating these studies’ finding to an Obamacare repeal is not easy and amounts a little to compare apples to oranges. The obvious caveat is that the two studies are heavily local, especially in Massachusetts, which has much better care and much more wealth than other states. Therefore, it is unclear how much the results in one American region can be scaled to the entire country. More largely, it highlights a thorny problem when it comes to the evaluation of an Obamacare repeal: how many (healthy) people would happily choose to drop their insurance, how many would do it because they can’t afford it, and how many would do it because of both? This is rendered all the more complicated by the relative leakiness of the Obamacare mandate, which may mean that the healthy people who would drop health insurance after a repeal have already done it.
More notably, the repeal of Obamacare is not a full repeal. For instance, the bills keep the Obamacare structure, with its private healthcare markets, in place. They also change the distribution of the health insurance subsidies, potentially altering the composition of the Americans with health insurance. This mean that, even if we could estimate the numbers of lives spared by Obamacare, it is not possible to consider that it would be the numbers of lives taken by an Obamacare repeal.
In conclusion, the assertion that the Republican bills will kill people is essentially speculative, but it probably is right. It is overwhelmingly likely that, if Republicans are able to repeal and/or replace Obamacare, millions more people will be uninsured in the medium-run, and a lack of health insurance is correlated to mortality.
But to advance a precise number is unjustified. It is unclear how much the population that would forego health insurance would be particularly prone to getting sick. Moreover, the studies that have estimated how many lives were spared by the extension of health insurance in other contexts display varying numbers. Now, all these caveats only make the estimate less reliable. It doesn’t necessarily mean that the number is necessarily going to be smaller. However, the level of assertiveness of some Democrats with regard to these death estimates is simply not warranted.