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What Rep. Raul Labrador, R-Idaho, told a restive town hall audience in Lewiston, Idaho, was destined to go viral. And it did.
At the May 5, 2017, event, questioners asked the congressman about the Republicans’ vote the previous day on a major health care overhaul that would roll back many aspects of President Barack Obama’s Affordable Care Act, including limits on expanding Medicaid, the federal-state health insurance program for the poor.
"You are mandating people on Medicaid accept dying," one audience member said.
To which Labrador responded, "No no, you know that line is so indefensible. Nobody dies because they don’t have access to health care."
The crowd howled in protest, and the comment drew immediate national attention. Writing in CNN, political commentator Chris Cillizza awarded his "Worst Week in Washington" award to Labrador, saying that the congressman had essentially handed Democrats a video clip that was "a ready-made attack line against every vulnerable House Republican."
Given all the attention to Labrador’s comment, we decided to fact-check it.
It’s not our first time looking at a similar question. Because of varied results from academic papers, we have struggled since 2009 about how to rate claims that a specific number of people die every year because they were uninsured -- a common talking point for Democrats. We found it difficult to pinpoint a specific number.
However, Labrador’s statement put a different twist on the question. Rather than saying that a specific number of people had died due to lack of health insurance, Labrador said that no one had. Could that be right?
When we contacted Labrador’s office, his staff pointed us to a Facebook post where he explained his remark the following day and accused the media for only focusing on a few seconds of a longer discussion.
"During ten hours of town halls, one of my answers about health care wasn’t very elegant," Labrador wrote. "I was responding to a false notion that the Republican health care plan will cause people to die in the streets, which I completely reject. ... In the five-second clip that the media is focusing on, I was trying to explain that all hospitals are required by law to treat patients in need of emergency care regardless of their ability to pay and that the Republican plan does not change that." (Here’s the full exchange as posted by Labrador’s office.)
However, even if you buy the argument that emergency room care would protect the uninsured, that leaves out a whole range of chronic and potentially deadly diseases -- from heart disease to diabetes -- that can be prevented only through long-term access to physicians.
A literature review
We found at least seven academic papers that detected a link between securing health insurance and a decline in mortality. In general, these papers present a stronger consensus that having insurance saves lives.
• In 2002, a panel of more than a dozen medical specialists convened by the federally chartered Institute of Medicine estimated that 18,000 Americans had died in 2000 because they were uninsured. In January 2008, Stan Dorn, a senior research associate at the Urban Institute, published a paper that sought to update the IOM study with newer data. Replicating the study’s methodology, Dorn concluded that the figure should be increased to 22,000.
• A 2009 American Journal of Public Health study concluded that a lack of health insurance "is associated with as many as 44,789 deaths in the United States, more than those caused by kidney disease."
• Three studies looked at state-level expansions of Medicaid and in each case found "significant" improvements in mortality after such expansions of coverage. These include a 2012 New England Journal of Medicine study of New York, Maine, and Arizona by Harvard researchers, and a 2014 study of Massachusetts by researchers from Harvard and the Urban Institute.
• A 2014 study published by the health policy publication Health Affairs looked at states that, at the time, had declined to expand Medicaid under the Affordable Care Act. It estimated that the 25 states studied would have collectively avoided between 7,000 and 17,000 deaths.
• A 2014 study in the Journal of Clinical Oncology found improved survival rates for young adults with cancer after securing insurance under the Affordable Care Act.
• A 2017 study in the journal Medical Care looked at a provision of the Affordable Care Act that allows young adults to be covered under a parent’s policy. The study found a decline in mortality among this population from diseases amenable to preventive treatment. (Mortality from trauma, such as car accidents, saw no decrease, as would be expected.)
Any contrary views?
We found two papers that might conceivably provide support for Labrador’s position. But as we’ll see, even the papers’ authors did not agree with Labrador.
• A paper published in April 2009 in HSR: Health Services Research. In it, Richard Kronick of the Department of Family and Preventive Medicine at the University of California (San Diego) School of Medicine, raised questions about the conclusions of the seminal Institute of Medicine study from 2002. Kronick’s study adjusted the data -- as the IOM had not -- for a number of demographic and health factors, including status as a smoker and body mass index, and found that doing so removed the excess number of deaths found in the original study.
• A 2013 paper in the New England Journal of Medicine co-authored by Katherine Baicker of Harvard University compared about 6,000 patients in Oregon who got coverage through a 2008 Medicaid expansion and about 6,000 who didn’t. While the study found improvements in out-of-pocket medical spending and lower rates of depression among those who got coverage, key benchmarks for physical health -- including blood pressure, cholesterol, and blood sugar -- did not improve in such patients.
So we asked both of these papers’ authors whether their papers could be used as justification for what Labrador said.
"Rep. Labrador is misinformed," Kronick said. "Common sense, as well as the accumulated weight of evidence is sufficient to convince any reasonable analyst that lack of health insurance results in excess morbidity (that is, sickness) and mortality."
Baicker, too, said she sees "strong evidence" that Labrador’s statement "is false. I agree that the exact number is up for debate, but the fact that it is more than zero seems clear to me."
Every other health policy analyst who responded to us for this article agreed that Labrador was wrong. Some saw common sense as equally persuasive as the peer-reviewed research.
"I was just at a physicians’ meeting where people described patients they had treated who had died because of a lack of coverage," said Harold Pollack, an urban public health researcher at the University of Chicago. "Everyone who does this for a living has personally experienced it in one way or another."
At the town hall, Labrador said, "Nobody dies because they don’t have access to health care."
Extensive research over the previous decade generally points to tangible reductions in mortality after patients obtain health insurance. Two papers found more equivocal results, but we reached authors of both papers, and they agreed that their findings do not support Labrador’s remark. While the exact number of deaths saved by having health insurance is uncertain, the researchers we contacted agreed that the number is higher than zero -- probably quite a bit higher.
We rate his statement Pants on Fire.
Raul Labrador, remarks at a town hall, May 5, 2017
Raul Labrador, Facebook post, May 6, 2017
Institute of Medicine, Care Without Coverage: Too Little, Too Late , released May 21, 2002
Stan Dorn, " Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality ," Urban Institute report, released January 2008
Institute of Medicine, America's Uninsured Crisis: Consequences for Health and Health Care , released Feb. 24, 2009
Richard Kronick, " Health Insurance Coverage and Mortality Revisited ," in HSR: Health Services Research, volume 44, issue 4, August 2009
American Journal of Public Health, "Health insurance and mortality in U.S. adults," December 2009
New England Journal of Medicine, "Mortality and Access to Care among Adults after State Medicaid Expansions," 2012
New England Journal of Medicine, "The Oregon Experiment — Effects of Medicaid on Clinical Outcomes," May 2, 2013
New England Journal of Medicine, "Mortality and access to care among adults after Medicaid expansions,"Sept. 13, 2013
Health Affairs blog, "Opting out of Medicaid expansion: the health and financial impacts," Jan. 30, 2014
Annals of Internal Medicine, "Changes in Mortality After Massachusetts Health Care Reform," 2014
Journal of Clinical Oncology, "Cancer-Specific Outcomes Among Young Adults Without Health Insurance," 2014
Medical Care, "The Affordable Care Act's Dependent Care Coverage and Mortality," May 2017
CNN, "Raul Labrador's worst week in Washington," May 8, 2017
PolitiFact, "Pascrell says up to 22,000 Americans die yearly because they don’t have health insurance," Aug 20, 2009
PolitiFact Florida, "Alan Grayson claims 45,000 people die a year because they lack health insurance," Aug. 30, 2013
PolitiFact Florida, "Charlie Crist says six Floridians die a day due to lack of Medicaid expansion," Feb. 12, 2014
Email interview with Henry J. Aaron, senior fellow at the Brookings Institution, May 8, 2017
Interview with Harold Pollack, urban public health researcher at the University of Chicago, May 8, 2017
Email interview with Richard Kronick of the Department of Family and Preventive Medicine at the University of California (San Diego) School of Medicine, May 8, 2017
Email interview with Katherine Baicker, professor of health economics in the Department of Health Policy and Management at Harvard University’s T.H. Chan School of Public Health, May 8, 2017
Email interview with Stan Dorn, senior fellow in the Health Policy Center at the Urban Institute, May 8, 2017
Email interview with Christine Eibner, chair of policy analysis at the RAND Corp., May 8, 2017
Email interview with Benjamin Sommers, associate professor of health policy and economics in the Department of Health Policy and Management at Harvard University's T.H. Chan School of Public Health, May 8, 2017
Email interview with Todd Winer, spokesman for Raul Labrador, May 8, 2017
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