COMMENTARY

Does Primary Care Really Save Lives?

Kenneth W. Lin, MD, MPH

Disclosures

July 07, 2017

Editorial Collaboration

Medscape &

Hi, I'm Dr Kenny Lin, a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

A few months ago, I argued that the American Health Care Act (AHCA), which the House of Representatives narrowly passed in early May, was a "path best not taken" because it did not address the concerns of primary care clinicians. Now the Senate is working on its own legislation. Although the Better Care Reconciliation Act is not identical to the AHCA, it has also been projected by the Congressional Budget Office to result in at least 20 million more uninsured persons by 2026, owing to restrictions on Medicaid spending, eliminating the Affordable Care Act's individual and employer mandates, and less generous premium subsidies for low-income people to obtain private health insurance.

Opponents of the House and Senate bills worry that the loss of health insurance will cause millions to delay or avoid necessary care, leading to worse health and premature deaths. Without a doubt, health insurance improves financial security by protecting people from large debts or bankruptcy due to medical bills. But whether having health insurance actually makes people healthier (and conversely, whether losing health insurance makes people sicker) is hard to know, because healthcare plays a relatively small role compared with social determinants—the conditions where people live, work, and play. Because people who lack health insurance are more likely to be unemployed or work part-time and live in communities with more crime and environmental health threats, being uninsured may simply be associated with poor health, rather than its cause.

Two recent literature reviews, one published in the New England Journal of Medicine[1] and the other in Annals of Internal Medicine,[2] analyzed studies connecting health insurance to mortality. Both found that being uninsured increases one's risk for premature death, and the Annals review concluded that having insurance was associated with a statistically significant reduction in overall mortality.

However, there are reasons to question these findings. Neither review team used a systematic process to identify relevant studies, so it is possible that some negative studies were excluded. The authors' backgrounds probably biased them toward interpreting the effects of health insurance in the most positive light. Both Annals authors are active in Physicians for a National Health Program. Less than a week after the New England Journal article was published, coauthor Atul Gawande wrote a New Yorker column[3] that sharply criticized the Senate bill as a threat to the nation's health and cited his own review to support his position.

Finally, the conclusion that health insurance reduces mortality is based on observational studies, rather than studies that randomly assigned people to insurance versus no insurance. The only randomized trial[4] occurred naturally in 2008, when Oregon expanded its Medicaid program to a limited number of previously uninsured adults, and instituted a lottery system to decide who would be offered coverage. A research team evaluated the expansion after 2 years and found that Medicaid-insured persons received more preventive services and diagnosis and treatment of diabetes, but there was no statistical difference in physical health measures or deaths.

On the basis of other studies, though, it is plausible that the positive effect of insurance on health is real. The next question is, why? It's not because insured people receive more or better care for acute, life-threatening illnesses. Instead, people who gain insurance generally increase their use of preventive services and are more likely to report having a usual source of primary care, which other studies have found is strongly associated with lower mortality.[5] In fact, I would argue that health insurance's positive effects on health are mediated largely through prepaid primary care services.

Health reform proposals should build on the knowledge that primary care saves lives for a fraction of the cost of a health insurance premium. In the long run, Democrats and Republicans could find common ground between their "Medicare for all" and "covering everyone costs too much" positions by removing primary care from the inefficient insurance system entirely. Instead, Congress should guarantee everyone a family doctor through a community health center or direct-pay primary care, as physician and financial planner Carolyn McClanahan has proposed.[6]

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

Follow Dr Kenny Lin on Twitter: @kennylinafp

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