Penn researchers — in collaboration with members of Yale University’s School of Public Health — projected over 51,000 preventable deaths each year as a result of the budget reconciliation bill passed by the House of Representatives.
In a June 3 memo addressed to Senators Ron Wyden (D-Ore.) and Bernie Sanders (I-Vt.), the researchers “estimated the number of lives that could be lost based on three effects of the reconciliation bill.” Their analysis projects that the bill’s combined changes — ranging from declines in insurance rates to the loss of minimum nursing home staffing requirements — could dramatically raise mortality nationwide.
Eric Roberts — who serves as a senior fellow at Penn’s Leonard Davis Institute of Health Economics — co-authored the letter alongside professors Rachel Werner, Norma Coe, and three peers at Yale’s School of Public Health.
“The research is the start of a public conversation around the broader consequences of policy,” Roberts said in an interview with The Daily Pennsylvanian. “This is really important for us to be talking about right now.”
Preventable death toll
According to researchers, over 42,500 annual deaths could result from three major provisions of the bill: 11,300 deaths from the loss of Medicaid or Affordable Care Act marketplace coverage; 18,200 deaths among low-income Medicare beneficiaries due to disenrollment from the Medicare Savings Programs; and 13,000 deaths among nursing home residents enrolled in Medicaid after the immediate revocation of the 2024 minimum staffing rule.
An estimated 7.7 million Americans are expected to lose Medicaid or Affordable Care Act marketplace coverage in 2034, and 1.38 million dual-eligible beneficiaries are expected to be unenrolled from the Medicare Savings Programs and lose coverage. The figures included in the letter are based on peer-reviewed studies that correlate health coverage loss with increased mortality, particularly among vulnerable populations. The analysis focuses on distinct at-risk groups and sums projected deaths across multiple categories.
The team’s projections are rooted in years of federally funded research, including Roberts’ decade-long study of Medicaid coverage effects on low-income older adults. His most recent work was published a month ago in the New England Journal of Medicine and examined a “natural experiment” — a real-world situation that mimics the conditions of a randomized trial.
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Roberts collaborated with Lilly Estenson, a graduate student at the University of Southern California with experience working with older adults struggling with coverage issues, to identify rules that allowed them to analyze how some low-income older adults lose Medicaid coverage at different times. This variation allowed researchers to compare mortality outcomes between similar groups who lost coverage.
“We estimated that if low-income older adults didn’t get Medicaid benefits and therefore did not get low-income prescription drug subsidies, there would be about 13 additional deaths per 1,000 individuals per year,” Roberts said. “That’s about a 1.3 percentage point increase in mortality on a baseline mortality rate of about 4% in that population. It’s like a 25-30% relative increase in mortality, which is substantial.”
The team identified that one provision — a 10-year delay in the implementation of Biden-era rules that would simplify Medicaid enrollment for low-income older adults — directly connected to their research. According to Roberts, the Congressional Budget Office previously projected that this delay would result in 1.38 million fewer low-income older adults having Medicaid coverage.
The researchers applied their mortality findings to this coverage loss projection to approximate 18,200 deaths annually.
“We took what the Congressional Budget Office said was the likely magnitude of insurance coverage loss in each of these groups,” Roberts said. “Then we took what we thought was the best evidence about the mortality effects of coverage for those populations and applied it to the coverage loss projections.”
The team used similar methodologies to analyze other provisions in the bill, drawing on established research that links coverage loss to mortality across different populations. The researchers highlighted an additional 8,811 deaths tied to the proposed expiration of enhanced ACA premium tax credits, which could leave 5 million more people uninsured.
The total number of Americans who would become uninsured at the implementation of this bill came to 13.7 million — which the researchers used to calculate the final prediction of 51,000 preventable deaths.
Research collaboration
Sens. Wyden and Sanders’ staff members reached out to Roberts’ team to see if the findings from their latest paper related to components of the House budget reconciliation bill.
The collaboration between Penn and Yale — coordinated by Werner, who is a national expert on nursing home policy — emerged specifically for this policy analysis. Werner and Coe contributed estimates on nursing home staffing effects, and Yale’s research team provided projections for Medicaid and marketplace coverage losses among working-age adults.
Roberts noted that the strength of the current evidence base made this kind of projection possible. They applied existing evidence to policy projections.
“Ten years ago, we didn’t have as strong evidence about the health effects of Medicaid coverage,” Roberts said. “We now have much stronger evidence that has been reproduced by multiple independent teams of researchers linking Medicaid expansion to lower mortality, particularly among adults with chronic conditions.”
The researchers also addressed concerns that the bill would protect vulnerable populations while implementing reforms. Roberts noted that the “architects of the bill stated that they are implementing these reforms to protect Medicaid for low-income people with disabilities, who are old and cannot work, and for children." He added that "their thesis" includes how a stricter eligibility requirement for working-aged people “helps to ensure program integrity.”
Roberts identified, however, pieces of the bills that counteract that claim.
“There are parts of the bill that directly affect Medicaid coverage for low-income, older adults and people with disabilities,” he said. “The delaying of rules that enable people to get and receive Medicaid who are low-income, elderly, or disabled would lead to a reduction in Medicaid coverage in that population.”
Additionally, parents’ insurance can impact kids’ access to healthcare. “If the parents aren't insured, good research shows that kids might be less likely to visit the doctor," Roberts added.
Roberts highlighted the nonpartisan nature of the team’s work, noting that while Democratic senators requested this analysis, he has previously responded to a similar request from a Republican lawmaker.
“We’re not writing to take a partisan stance … We really want to be engaged in disseminating our research to help policymakers,” he said. “We recognize that as stewards of taxpayer dollars when we are doing research that is funded through the U.S. government. We take that responsibility very seriously.”
The letter concluded with an offer to provide further detail or consultation to lawmakers aiming to assess the full public health implications of the proposed legislation.
Penn researchers have historically played a role in assessing the consequences of administrative changes, including research cuts and layoffs across industries.
