Was the Affordable Care Act (ACA) worth it? Should it be seen as a “favorite moment” and “victory,” a legacy of the Obama Administration to build on in the future? Were the other positive and negative results for health care of pursuing and passing the ACA worth the very high political cost of passing this program and implementing it?

When the President and the Democrats took up health insurance reform, mistakenly characterized by them and others as health care reform, the motivation was the carnage out there in the relations between the insurance industry and the population in the years leading up to 2009. People had begun talking about health insurance companies committing “murder by spreadsheet.”

There were then four very important consequences of the existing non-system of health care insurance: first, fatalities due to lack of insurance (thought to be approximately 45,000 annually in 2009); second, bankruptcies; third, mortgage foreclosures; and fourth, divorces; the last three due to the stresses created by unpaid medical bills, all in the millions, or hundreds of thousands, annually, as the case may be. This post will focus on fatality estimates associated with the ACA compared to enhanced Medicare for All.

The choice to pursue a government-regulated private sector insurance solution through seeking bipartisan consensus in Congress, rather than use Democratic majorities in both Houses to pass and immediately implement a Medicare for All bill, ensured that a health insurance reform bill would not be implemented in 2009. So, there could have been no impact on fatalities in that year, and only a small impact in 2010.

In 2008, estimated annual fatalities (see note below) due to lack of insurance were at 57,345. In 2009, estimated fatalities increased substantially to 62,730. This increase was probably due to the effects of the Great Recession, which drove U-3 unemployment up to 10% in October 2009, causing the number of uninsured to rise, and resulting in the increase in fatalities.

The ACA legislation deliberately postponed its full implementation until 2014, with incremental implementation in the years before that. In 2010, there was hardly a ripple from the new law.

The rate of increase in coverage and fatalities slowed considerably. Part of that improvement was likely due to the beginning of economic recovery, but it wasn’t strong enough to overcome the growth in population and the number of uninsured, so estimated fatalities rose to 63,967.

In 2011, the number of both estimated uninsured, and fatalities decreased slightly for the first time. To what extent this was due to the economic recovery as opposed to the ACA isn’t clear. However, annual fatalities decreased for the first time to 62,254.

The number of uninsured and fatalities continued to decrease in 2012, as more of the ACA was implemented. But the decrease in fatalities to 61,406 was small.

Progress in reducing the number of fatalities due to lack of insurance accelerated substantially during the next three years. In 2013, as more of the act was rolled out, estimated fatalities among the uninsured due to lack of insurance decreased to 53,253. And the year of full rollout in 2014 saw a further decrease to 42,219, and then to 37,094 in 2015.

So, estimated fatalities from 2010 through 2015 associated with the ACA totaled: 320,463, with probably an additional 35,000 to be estimated from as yet unavailable 2016 data, resulting in a grand total estimate of approximately 355,000 avoidable fatalities. These fatalities could have been reduced to numbers close to zero if an enhanced Medicare for All bill had been passed in early 2009 and rolled out in that year.

So, was the passage of Obamacare a favorite legacy moment of the Obama Administration, a victory never to be forgotten? 355,000 lives is a lot of lives to lose as a consequence of a political decision. It’s nearly as many fatalities as the US suffered during World War II.

The Obama Administration had the lead role in shaping the path that led to the ACA’s passage and implementation. So, it has to bear much of the responsibility for allowing the health insurance company-related carnage to continue after 2009.

The ACA, up to 2016, stopped about one-half the annual fatalities that likely would have occurred if there were no changes in policy. In general, solving half of a problem, when the right policy could have ended it, is mediocre performance.

But when that problem is about ending avoidable deaths with a government policy, it is poor performance. And when hundreds of thousands of people can be kept alive through a well – known policy that has been successful in many other nations, and you just refuse to propose that policy, much less fight for it, then that’s political malpractice – not a great legislative achievement, or a “legacy” moment worth celebrating.

Note: The fatality numbers provided in this post differ from those frequently reported. They are about 30 percent higher They were arrived at by using US Census Bureau estimates of the annual numbers of health care uninsured, for 2010 through 2015 and multiplying by 0.0012806, a ratio of fatalities to the number of uninsured resulting from adjusting another ratio developed in a well-known Harvard study of the 18 – 64 population in 2005.

The adjustment was made to compensate for the absence of those under 18 and over 64 in the study in order to arrive at estimates applying to the population as a whole. The methodology of the original study and the adjustment is analyzed here.