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 September 30, 2019
As Trump and GOP try to dismantle Affordable Care Act, evidence suggests law has made people healthier

 Poor people in Michigan with asthma and diabetes were admitted to the hospital less often after they joined Medicaid under the Affordable Care Act. More than 25,000 Ohio smokers got help through the state's Medicaid expansion that led them to quit. And around the country, patients with advanced kidney disease who went on dialysis were more likely to be alive a year later if they lived in a Medicaid-expansion state.

Such findings are part of an emerging mosaic of evidence that, nearly a decade after it became one of the most polarizing health-care laws in U.S. history, the ACA is making some Americans healthier --- and less likely to die.

The evidence is accumulating just as the ACA's future is, once again, being cast into doubt. The most immediate threat arises from a federal lawsuit, brought by a group of Republican state attorneys general, that challenges the law's constitutionality. A trial court judge in Texas ruled late last year that the entire law is invalid, and an opinion on the case is expected at any time from the U.S. Court of Appeals for the Fifth Circuit. The case could well put the ACA before the Supreme Court for a third time.

President Trump has dismantled as much of the law as his administration can, by expanding the availability of skimpy, inexpensive health plans that skirt ACA rules, for example, and slashing federal aid to help people sign up for coverage through ACA insurance marketplaces.

And some 2020 Democratic presidential candidates contend the country needs further-reaching health reforms than the ACA, calling for a government-financed system they call Medicare-for-all.

The law's supporters have not taken political advantage of the signs that the ACA is translating into better health --- at least, not yet.

When the sprawling 2010 statute was new, a central question was whether it would help more people gain affordable health coverage, as intended.

With about 20 million Americans now covered through private health plans under the ACA's insurance marketplaces or Medicaid expansions, researchers have been focusing on a question that was not an explicit goal of the law: whether anyone is healthier as a result.

It is difficult to prove conclusively that the law has made a difference in people's health, but some strong evidence has emerged in the past few years. Compared with similar people who have stable coverage through their jobs, previously uninsured people who bought ACA health plans with federal subsidies had a big jump in detection of high blood pressure and in the number of prescriptions they had filled, according to a 2018 study in the journal Health Affairs.

And after the law allowed young adults to stay longer on their parents' insurance policies, fewer 19- to 25-year-olds with asthma failed to see a doctor because it cost too much, according to an analysis of survey results published earlier this year by researchers at the U.S. Centers for Disease Control and Prevention.

Most of the emerging evidence concentrates on the health effects of joining Medicaid under the law's expansion of the safety-net program. Medicaid is an appealing research focus because a 2012 Supreme Court decision gave each state the option to widen eligibility to people who are somewhat less poor, allowing comparisons between the three dozen states that have expanded and the rest that have not. In addition, low-income people without insurance are most likely to have built-up medical problems that get treated once they get covered.

Michigan has emerged as a hub for understanding the ACA's effects on health because University of Michigan researchers have been rigorously evaluating the Healthy Michigan Plan, as the state calls its Medicaid expansion covering about 650,000 people.

One 2017 study compared heart surgery patients in Michigan and Virginia, which had not yet expanded Medicaid at the time. It found that those who had cardiac bypasses or valve operations in Michigan had fewer complications afterward than similar people in Virginia, where more were uninsured.

One in three Michigan women said that, after joining Medicaid, they could more easily get birth control. And four in 10 people in Healthy Michigan with a chronic health condition --- such as high blood pressure, a mood disorder or chronic lung disease --- learned of it only after getting the coverage, according to survey results published this month.

In a few neighborhoods here in Detroit, the consequences for patients and their doctors are clear.

*****

Bonnie Sparks, dripping sweat in a mint green T-shirt, reached the finish line of the CHASS community health center's 5K run/walk. As she trudged the final steps, the center's chief medical officer Richard Bryce urged workers and some medical students to walk alongside her in the 97-degree heat, chanting her name. Then, Bryce wrapped Sparks in a hug.

Sparks came in last of the event's 270 runners and walkers in late July in a southwest Detroit neighborhood pocked with vacant lots. She was halfway to Clark Park when the center's executive director found her at the back of the pack and offered a ride. "No way," Sparks said, insisting on continuing under her own power.

The miracle was that, at 47, she walked the course at all.

CHASS has been a medical haven in Detroit's Mexicantown for a half-century, since the city's riots prompted hospitals to close and physicians to move to the suburbs. Five years ago, when Bryce, a family physician, arrived and took over Sparks' care, she weighed more than 300 pounds and could not get from the clinic parking lot to the front door without help. She'd had her first heart attack at 34. Her anxiety was so sharp she often could not leave her apartment. On a rare family road trip --- to Daytona Beach --- she waded into the Florida waters where flesh-eating bacteria infected an open sore on her right leg. Back home, she landed in the hospital for 3 1/2 weeks.

For 13 years, Sparks had worked for a defense contractor, NCI Information Systems, overseeing two computer help desks. But when the company lost a contract, her job ended in late 2010, and her good HMO insurance disappeared.

Living on unemployment, she kept taking pills for her diabetes and high blood pressure, because she could get the prescriptions for $4 a month through a Walmart discount. But she did not have the $300 a month to pay for Plavix --- a blood thinner she needed because of a stent put in her heart --- so she stopped.

"I talked to my doctor at the time. I said, 'I can't afford this,' " recalls Sparks. "He said, 'You could have another heart attack.'

"And I did."

The second heart attack, in early 2012, was serious. Afterward, her doctors told her she should not work. She applied for Medicaid twice and received form letters telling her she was denied because she was not under 21, pregnant, blind or taking care of a child.

The following year, she appealed in writing, then asked for a hearing, but a state administrative law judge concluded that, though Sparks had a solid job history and significant medical problems that made it difficult for her to work, she was not technically disabled so did not qualify for insurance.

"I felt abandoned," Sparks recalls. "I nearly died. I kept thinking, 'I am just sick right now.' "

So Sparks was uninsured when her boyfriend rushed her to an emergency room for a second time within days after the Florida trip. This time, she was diagnosed with the flesh-eating necrotizing fasciitis. She was in breathing distress and kidney failure because of the infection and was placed in a medically induced coma for most of her time in the Henry Ford Hospital.

But the day she was admitted, April 3, 2014, was the third day that the state had begun accepting applications for the Healthy Michigan Plan. On April 29, Sparks got a letter. She was insured.

Medicaid paid her $132,000 hospital bill.

Since then, social workers and a psychologist have helped ease her out of her smoking habit and her anxiety. She met with a bariatric surgeon to consider a gastric bypass, but, by that point, had started to lose so much weight by improving her diet and walking that she decided she did not need the surgery. Last month, she was down to 234 pounds.

Sparks has an endocrinologist for her diabetes. A cardiologist approved a catheterization when she had more chest pains --- and inserted additional stents. And she has an OB/GYN who treated her worsening fibroids and, when they got too severe, made sure she got a hysterectomy.

Bryce, who arrived at CHASS at about the time of Sparks' infection, says she was like many sick and uninsured patients who can get primary care through the health center but have trouble finding medical specialists willing to treat them.

If not for the health plan she has through Healthy Michigan and Medicare, which she has had since the state eventually classified her as disabled, Sparks said, "I would be dead, or I would be financially ruined."

On the east side of Detroit, the part of town where poverty and illness are most common and life expectancy is shortest, Healthy Michigan has transformed the lives of patients at the Mercy Primary Care Clinic. Like Sparks, David Brown says that, without it, "I probably would not be here. I would have had a heart attack and died."

Before Medicaid expanded, all of Mercy's patients were uninsured. Now, at 55, Brown is among the half at the clinic covered by Healthy Michigan.

Right after he got laid off in 2007 from a job with Wayne County, driving trucks and front-end loaders at the airport, he began having spells in which his chest was tight, his head spinning. Finally, a friend took him to an emergency room. He was prescribed rest and ordered to follow up with his primary care doctor. Except he did not have one.

Over the next few years, the spells came more often, and he was going to emergency rooms around town, dizzy and with headaches, two or three times a month. When the bills showed up, he stored them, unpaid, in the brown plastic crates where he keeps files.

He does not remember anyone checking his blood sugar, even though his favorite foods were fried chicken, Burger King, cinnamon doughnuts, chocolate milk and --- especially --- Snickers bars.

Finally, during an emergency room visit, someone mentioned he might be borderline diabetic.

When he finally heard about Mercy and was diagnosed with diabetes by Pamela Williams, a staff physician, Brown recalls, "she started telling me what could happen --- amputation, kidney failure, heart failure. I was like, 'I could lose my foot, my hand?' I had never heard of anything like that."

On a Mediterranean diet, Brown, also a licensed pastor who does online counseling, has gone from 340 pounds to 215. His blood sugar has been under control the past few years.

"But unfortunately, the damage was done when he didn't have insurance," Williams says.

With coverage from Healthy Michigan, Brown sees a nephrologist for his chronic kidney disease, a cardiologist for his congestive heart failure, an ophthalmologist for eye damage --- all downstream effects of the years he did not know he had out-of-control diabetes.

Brown now has three stents in his heart, including a new one this summer after he had balloon angioplasty to open a clogged artery. He takes medicines that, if he had to pay retail, would cost about $2,400 a month.

"This stuff was not available to me without insurance," Brown says. "I am grateful for it."

****

Understanding the ways the ACA has affected Americans' health is a work in progress. In the law's first years, results were mixed, but signs of improvements have accelerated lately, as people uninsured before now have more years of coverage, giving researchers better data to study.

It is too soon to know whether the patterns might reverse with new U.S. Census Bureau data showing that the uninsured rate rose significantly last year for the first time since the ACA has existed.

The findings that exist are not perfect. One National Bureau of Economic Research paper in July, looking at deaths from all causes among adults from their mid-50s to mid-60s, found that dying in a given year has been significantly less common in the states that expanded Medicaid. The paper said that perhaps 15,600 deaths could have been avoided if the expansion had been nationwide, but cautioned that is a rough estimate in part because the study was unable to look specifically at the people who signed up for Medicaid.

Similarly, a study last year found that infant deaths --- especially among black babies --- were dropping more rapidly in parts of the county that had expanded Medicaid. But the study does not distinguish families who got coverage through the ACA expansions.

The University of Michigan work, including on trends in hospital stays for four main chronic diseases, was able to focus specifically on people who had joined Healthy Michigan. It found that from the first year in the program to the second, hospital stays for asthma plummeted by half and also fell for diabetes complications. But hospital stays for heart failure became more common. The researchers have not yet looked at the patterns for additional years.

Still, John Ayanian, director of the University of Michigan's Institute for Healthcare Policy and Innovation, said, "the weight of evidence is on the positive side."