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Excess Deaths Among the Uninsured Before the Affordable Care Act (ACA), and Potential Post-ACA Reductions

Powell, Dumbiri J. MPH; Xirasagar, Sudha MBBS, PhD

Journal of Public Health Management and Practice: May/June 2017 - Volume 23 - Issue 3 - p e18–e28
doi: 10.1097/PHH.0000000000000428
Research Articles

Context: Despite implementation of the Affordable Care Act (ACA), as of 2015, about 25.8 million working-age Americans remained uninsured and vulnerable to premature death because of poor health care access. The ACA-mandated phasing out of disproportionate share hospital payments that supported charity care may aggravate care access for the residual uninsured.

Objectives: To estimate excess deaths among the uninsured and the potential ACA impact on the basis of a recent cohort's mortality experience. We hypothesized a higher uninsured mortality risk than the available pre-2000 estimate because of worsening of care disparities owing to technology-driven advances in life-saving care.

Design: We conducted a retrospective cohort study of the 1999 to 2002 National Health and Nutrition Examination Survey respondents observed through 2011. We estimated (a) weighted Cox proportional mortality hazard of uninsured working-age adults adjusted for demographics, comorbidity, and lifestyle behaviors, (b) weighted mortality rates among the uninsured and insured within age and comorbidity strata, and (c) excess deaths because of uninsurance using the Institute of Medicine methodology.

Setting: Noninstitutionalized US population.

Participants: Adults aged 20 to 64 years.

Main Outcome Measure: Mortality.

Results: Of 7274 study-eligible respondents, 20.6% were uninsured and 478 died during follow-up, for an adjusted uninsured mortality hazard ratio of 1.57 (95% confidence interval, 1.12-2.21) versus privately insured, translating to 48 529 excess deaths among the population aged 25 to 64 years in 2011 (7.8% of total deaths in this age group). The estimated proportion of excess deaths was 52% higher than the pre-2000 cohort study. The mortality disparity increased with age and comorbidity.

Conclusions: Findings support our hypotheses, and indicate that post-ACA, a residual 4.7% excess mortality among working-age adults will continue, about 30 428 excess deaths annually. Restoration of disproportionate share hospital supports and continued advocacy for universal health care coverage are needed to reduce avoidable deaths.

Supplemental Digital Content is Available in the Text.

Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.

Correspondence: Sudha Xirasagar, MBBS, PhD, Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene St, Columbia, SC 29208 (

The study results were presented at the Academy Health Annual Research Meeting, Minneapolis, Minnesota, June 15, 2015, and the South Carolina Public Health Association Annual Conference, Columbia, South Carolina, May 20, 2015.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

The authors declare no conflicts of interest.

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