To understand how the Senate Republicans’ health-care bill would affect
people’s actual health, the first thing you have to understand is that
incremental care—regular, ongoing care as opposed to heroic, emergency
care—is the greatest source of value in modern medicine. There is clear
evidence that people who get sufficient incremental care enjoy better prevention,
earlier diagnosis and management of urgent conditions, better control of
chronic illnesses, and longer life spans.

When more people get health-insurance coverage, as they did following
the implementation of the Affordable Care Act, they get more incremental
care. This week, the New England Journal of Medicine published a
paper that I
co-authored with Katherine Baicker and Ben Sommers, two health
economists at the Harvard T. H. Chan School of Public Health, in which
we analyzed the health effects of insurance coverage. We looked at
dozens of studies put out over the last decade, and found that
insurance-coverage expansions—including not just the A.C.A but also past
Medicaid expansions and the health-care reform that Massachusetts passed
in 2006—have consistently and significantly increased the number of
people who have a regular source of care and who can afford the care
they need. Insurance expansions have made people more likely to get
primary and preventive care, chronic-illness care, and needed
medications—including cancer screenings, diabetes and blood-pressure
medicines, depression treatment, and surgery for cancer before it is too
late.

These improvements in care help explain why people who have health
insurance are twenty-five per cent more likely to report being in good
or excellent health. It also explains why they become less likely to
die. Proper health care saves lives, and the magnitude of the reduction
in deaths increases over time. The longest study we looked at analyzed
Medicaid expansions that occurred in the early two-thousands in Arizona,
Maine, and New York. Five years after the expansions, mortality rates
for recipients had fallen by six per
cent compared with matched populations in states that didn’t expand Medicaid.
More broadly, when we looked at the data from all the large studies in
our set, we found that, for every three hundred to eight hundred people
who gained coverage, one life was ultimately saved per year. The biggest
gains came, as would be expected, among patients with chronic or
semi-chronic conditions, such as heart disease, cancer, H.I.V., and other
infections.

Conservatives often take a narrow view of the value of health insurance:
they focus on catastrophic events such as emergencies and sudden,
high-cost illnesses. But the path of life isn’t one of steady health
punctuated by brief crises. Most of us accumulate costly, often chronic
health issues as we age. These issues can often be delayed, managed, and
controlled if we have good health care—and can’t be if we don’t.

Conservatives also dismiss Medicaid by arguing that it provides
inadequate or unsatisfactory coverage. The opposite is true, according
to the evidence. Compared with private coverage, Medicaid produces at
least as much improvement in access to care, measures of health, and
mortality reduction. And polls indicate that recipients like Medicaid
more than private coverage, even with the difficulties finding doctors
who take Medicaid, because the program provides them with better
financial protection.

Despite these facts, the Senate reform bill, like the bill that House
Republicans passed earlier this year, would hollow out or terminate
coverage for tens of millions of Americans who rely on Medicaid or the
private-insurance exchanges set up by the A.C.A. These bills are, in
many ways, Medicaid-repeal bills masquerading as Obamacare-repeal bills.
And Medicaid, remember, is not a program that the public is complaining
about. It is immensely
popular and works well. It provides
coverage for sixty per cent of disabled children, and maternity coverage for half
of pregnant women. Two-thirds of nursing-home residents end up relying
on Medicaid coverage after their savings are spent. Among adult Medicaid
recipients, sixty per cent work, and eighty per cent are part of working
families.

President Trump, who has expressed his support for the Senate bill,
campaigned on a specific promise not to cut Medicaid, and the White
House continues to peddle a claim that, as Sean Spicer put it
on Friday,
the President is “committed to making sure that no one who currently is
in the Medicaid program is affected in any way, which is reflected in
the Senate bill, and he’s pleased with that.” But this statement does
not reflect reality—the Senate proposal would not only roll back the
A.C.A.’s Medicaid expansion but go even further, capping
Medicaid expenditures at levels even lower than those that would have
been in place without the A.C.A.

The Senate bill would also ultimately make people who buy insurance on
the A.C.A. exchanges—people without coverage from an employer or from
Medicaid—pay far more money for far worse coverage, especially if they
are age fifty or older. The standard “reference” plan on the exchanges
would cover barely more than half of medical costs, while cost-sharing
subsidies for working-class people would be eliminated, and the level of
tax credits available to them would be cut, too. The result: the median
deductible would jump from the current five hundred dollars to more than
six thousand
dollars.
The annual premium for a sixty-year-old earning fifty thousand dollars
in my home town of Athens, Ohio, would
triple, to fourteen thousand dollars. In many parts of the country, things would
be much worse. (In Anchorage, Alaska, for example, premiums would be
thirty-six thousand dollars.) The bill, in other words, promises
terrible coverage at unaffordable prices. Millions of people would have to give up insurance, leaving them without protection and the entire individual-insurance market at risk of collapse.

The trade-offs here are indefensible. The bill would take a trillion
dollars away from health coverage for the bottom fifty per cent of the
population to give a tax cut to the top two per cent. The Center on
Budget and Policy Priorities did the
math:
one consequence of the legislation is that three-quarters of a million
people would be thrown off of the Medicaid rolls to give the four
hundred highest earners in the country a thirty-three-billion-dollar tax
cut. The bill would put thousands of nursing homes, clinics, and
hospitals into financial trouble. And for patients it would mean more
medical debts, more untreated sickness, and more deaths. A basic test of
government is its ability to prevent large-scale harm to its citizens’
health and survival. This bill, and this Administration, are failing
that test.