Lancet series: “America: equity and equality in health”

Yesterday, the Lancet published a new series “America: equity and equality in health.”  It is available online for free (you need only to register on the site).  In addition to the five papers (below), there is an accompanying editorial as well as comments from Senator Bernie Sanders and Thomas Sequist.  I had the pleasure of co-writing the paper on the Affordable Care Act with colleague/mentor, Dr. Danny McCormack.  The papers are:

  • “Inequality and the health-care system in the USA”,  Samuel L Dickman, David U Himmelstein, Steffie Woolhandler
  • “The Affordable Care Act: implications for health-care equity,” Adam Gaffney, Danny McCormick
  • “Population health in an era of rising income inequality: USA, 1980–2015,” Jacob Bor, Gregory H Cohen, Sandro Galea
  • “Structural racism and health inequities in the USA: evidence and interventions,”   Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett
  • “Mass incarceration, public health, and widening inequality in the USA,” Christopher Wildeman, Emily A Wang


Blog: Canada’s single payer system produces better outcomes for CF patients than the US system

An important study was published this week in the Annals of Internal Medicine, “Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States,” by Anne L. Stephenson and colleagues.1  The investigators used cystic fibrosis (CF) registries in the United States and Canada to compare outcomes for these patients between the two countries, and the bottom line made headlines in major media outlets: Canadian CF patients did better—much better—indeed they lived some 10 years longer than US CF patients.  The investigators found 34% lower mortality for Canadian CF patients even after controlling for a wide variety of patient and clinical characteristics, including genotype, an important marker of disease severity.  This difference was demonstrated in multiple subgroup analyses (for instance, when looking only at delta F508 homozygotes).    Moreover, over time, Canadian CF patients saw greater improvements in life expectancy.  Finally, they were also more likely to receive organ transplants.

Thus, despite the often-vaunted superiority of the American healthcare system, here is yet another piece of evidence that single payer public systems can deliver better results—indeed in this case the Canadian system even provided more high-technological care (i.e. transplants), which is supposed to be our specialty.

There is one additional finer point to make.  When examining US CF patients by insurance status, the investigators found that those with private insurance did not do significantly worse than Canadian CF patients, whereas the uninsured and those with Medicare/Medicaid (treated as one category) did.  Does this somehow provide evidence that private insurance is superior to public insurance, or does it weaken the overall point that the Canadian single payer system better served CF patients?  No, for a number of reasons.  First, Medicaid, as important as it is, does in fact sometimes provide a lower tier of access to medical care:  for instance, CF patients with Medicaid are less likely to be accepted for a lung transplantation in the US.2  Thus, even apart from the possibility of residual confounding given the association of Medicaid with lower socioeconomic status, it would not be surprising to find worse outcomes for those with Medicaid as compared to those with private insurance in the US.  Second, it is hard to use this study to say much about Medicare.  In part, this is because subjects with Medicaid and Medicare were combined into a single group, so it’s unclear which (or both) of these populations were driving the finding.  Additionally, those under 65 can only get Medicare if they are disabled.  Comparing this disabled CF population to a general Canadian CF population would leave the door open for residual confounding.

  1. Stephenson AL, Sykes J, Stanojevic S, et al. Survival comparison of patients with cystic fibrosis in canada and the united states: A population-based cohort study. Annals of internal medicine 2017.
  2. Quon BS, Psoter K, Mayer-Hamblett N, Aitken ML, Li CI, Goss CH. Disparities in Access to Lung Transplantation for Patients with Cystic Fibrosis by Socioeconomic Status. American Journal of Respiratory and Critical Care Medicine 2012;186:1008-13.

Body Count from ACA Repeal without real replacement, updated

Last November, I published a short post with rough estimates of the potential number of deaths per year that could result from a repeal of the ACA that was unaccompanied by a real replacement, and provided a rough range of 20,110 – 48,352 excess deaths (based on the “number needed to insure” from two studies as calculated by Sam Dickman et al. and the CBO’s estimate of 22 million more uninsured under Republican legislation).

Since then, we have some new estimates of the number of excess uninsured under repeal legislation.  Bernie Sanders tweeted about the number of deaths that could result from ACA repeal, relying on other assumptions:

The Washington Post criticized the number, and assigned Bernie’s tweet four “pinocchios.”  However, as Professors of Public Health David Himmelstein and Steffie Woolhandler (and PNHP co-founders) responded in an article also in the Post, Sanders number may actually be too low: they provided an estimate greater than 40,000 (based on 20 million uninsured).  Here’s Atul Gawande responding to Himmelstein and Woolhandlers’ figure:

Of course, depending on the exact assumptions used, a range of numbers of estimated deaths can be calculated.  The following table provides the potential range of estimated excess deaths per year depending on the assumption utilized.




Number needed to insure
Source Legislation Number uninsured “Low” estimate1 “Middle” estimate2 “High” estimate3
455 830 1094
HHS4 Number insured by ACA 20,000,000 43,956 24,096 18,282
Congressional Budget Office5



Restoring American’s Healthcare Freedom Reconciliation Act of 2015


18,000,000 39,560 21,687 16,453
(subsequent) 27,000,000 59,341 32,530 24,680
(2026) 32,000,000 70,330 38,554 29,250
Urban Institute6 “repeal via reconciliation without replacement” 29,800,000 65,495 35,904 27,239

Needless to say, all are rough approximations.  What is important is that many body bags will be necessary if we gut the ACA, numbering in the tens of thousands.  Many of these are approximations are even higher than that of Woolstein and Himmelhandler.

Of course, even with the ACA, we will have an estimated 26 million uninsured for 2017, according to the CBO, so the status quo is also very inadequate.



1  Sommers, B. D., S. K. Long, and K. Baicker. “Changes in Mortality after Massachusetts Health Care Reform: A Quasi-Experimental Study.” Annals of Internal Medicine 160, no. 9 (2014): 585-93.  Number needed to insure based on this study as calculated by:  Dickman, Sam, David Himmelstein, Danny McCormick, and Steffie Woolhandler. “Opting out of Medicaid expansion: the health and financial impacts.” Health Affairs Blog, January 30 (2014).  Available at:

2 Sommers, Benjamin D., Katherine Baicker, and Arnold M. Epstein. “Mortality and Access to Care among Adults after State Medicaid Expansions.” New England Journal of Medicine 367, no. 11 (2012): 1025-34.

3  Wilper, A. P., S. Woolhandler, K. E. Lasser, D. McCormick, D. H. Bor, and D. U. Himmelstein. “Health Insurance and Mortality in US Adults.” Am J Public Health 99, no. 12 (Dec 2009): 2289-95.  Number needed to insure based on this study as calculated by:  Dickman, Sam, David Himmelstein, Danny McCormick, and Steffie Woolhandler. “Opting out of Medicaid expansion: the health and financial impacts.” Health Affairs Blog, January 30 (2014).  Available at:





Updated to reflect “low estimate” of 455 number needed to insure, not 457.