Benefits of insurance coverage no longer in question, but jury still out on cost

Weight scales
Recent studies show increased health insurance coverage benefits outcomes, but policymakers still need to weigh those benefits against their costs, according to an NEJM article. (Pixabay/xibarodays)

Increasing health insurance coverage appears to improve health outcomes, according to recent studies, but the jury’s still out on whether the costs are worthwhile.

In a piece for the New England Journal of Medicine, Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., and Katherine Baicker, Ph.D., surveyed the available data that looked at expanded insurance coverage provided by the Affordable Care Act. They draw an important distinction between improvements in outcomes and whether the cost of the reforms justifies the degree of improvement. The latter represents a much thornier question, and a more difficult one to answer.

The authors see strong evidence that the ACA has improved outcomes:


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  • Studies have generally shown improved mortality rates under healthcare reform, particularly those looking at the differences between states that took advantage of expanded Medicaid coverage under the ACA.
  • The authors see “strong evidence” supporting a link between coverage expansion and access to preventive care. A concomitant rise in trips to the emergency department suggests that, while important, some of the increased access may go to “low-value care” or “poor outpatient care.”
  • Individuals with chronic conditions have seen a mixed bag of improvements, with strong results among those suffering depression and some cancers, but more ambiguous results among those suffering from diabetes, asthma, kidney disease, or heart failure. On the whole, however, the authors note that “studies do show that for persons reporting any chronic condition, gaining coverage increases access to regular care for those conditions.”

Increased access to care and increased utilization of care mean an increase in cost, however. Despite the myriad policy proposals for cost controls and the distribution of expenses among public and private entities, the authors wrote that no scenario to date has shown expanded insurance coverage to reduce overall healthcare expenditures by society.

That still begs the question of whether the cost of subsidizing care is ultimately worth it, and the answer can be slippery: The authors point to estimates suggesting the Medicaid expansion’s decreases in mortality work out to a fraction of the cost of other public policies with similar goals.

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