Three landmark Supreme Court decisions in 2022 have each been widely criticized by health experts as threats to public health, but a study released Thursday in JAMA Network Open modeled their collective toll. The study found that, by conservative estimates, the decisions will lead to thousands of deaths in the coming years, with tens of thousands more being harmed.
The three decisions included: one from January 13, 2022, that invalidated some COVID-19 workplace protections (National Federation of Independent Business v Department of Labor, Occupational Safety and Health Administration (OSHA)); one on June 23, 2022, that voided some state laws restricting handgun carry (New York State Rifle and Pistol Association Inc v Superintendent of New York State Police (Bruen)); and one on June 24, 2022, that revoked the constitutional right to abortion (Dobbs v Jackson Women’s Health Organization).
A group of health researchers, led by Adam Gaffney at Harvard University, modeled how these decisions would impact Americans' morbidity and mortality in the near future.
COVID deaths and harms
For the OSHA decision, the researchers drew upon OSHA's estimates of the number of workers who would have been vaccinated under the agency's emergency temporary standard (ETS), which would have required large employers to have employees vaccinated or take precautions such as masking and testing. OSHA estimated that implementation of the ETC would have led to 18.9 million more people getting vaccinated at the time, which coincided with the initial omicron wave.
The study authors modeled three scenarios, varying the times at which the implementation came into effect amid the infection surge in January and February 2022, drawing on data from the Centers for Disease Control and Prevention to assess deaths by vaccination status, age, and calendar week in the implementation period. They also modeled the rates of hospitalizations, intensive care admission, and use of mechanical ventilation.
Between January and May 2022, invalidating the OSHA ETS was estimated to be associated with between 980 and 2,940 deaths, with a middle estimate of 1,402. Additionally, hospitalization estimates ranged from nearly 16,000 to 48,000, with a middle scenario of just under 23,000. Estimated cases needing intensive care and mechanical ventilation middled at nearly 4,000 and 1,500, respectively.
Firearm deaths and harms
For the Bruen decision, the authors reviewed seven recent studies estimating the increased rate of firearm-related homicides associated with dropping "may-issue" concealed-carry permits for handguns. The Supreme Court's ruling voided such laws in six states (California, Hawaii, Maryland, Massachusetts, New York, and New Jersey) and the District of Columbia. Based on the literature review, Gaffney and colleagues estimated homicide-rate increases ranging from 3 percent to 9 percent. That set up modeling for three scenarios, with a mid-level increase of 6 percent, based on CDC data on firearm-related homicide rates in the affected states and DC. They also modeled three scenarios in which states offset the effects of voiding the laws with new policies, either completely, partially, or not at all.
In all, the middle scenario estimated an increase of 152 additional fire-arm related deaths per year, with 377 additional nonfatal firearm injuries.
Pregnancy-related deaths and harms
For the Dobbs decision, the authors modeled out the projected deaths just based on the mandatory continuation of pregnancy in people who otherwise would have ended the pregnancy. Previous research has estimated that pregnant people are 14 times more likely to die from a pregnancy than from legal, induced abortions.
Gaffney and co-authors built on previous estimates of foregone abortions in a post-Roe America, based on a national data set of abortion facilities and driving distances from the center of each county to the nearest facility. The authors used previous estimates of how distance to the nearest facility reduces rates of abortion. They also modeled two scenarios, looking at the impacts of facilities closing in the 13 states that had trigger bans and a second scenario that included facility closures of 10 additional states considered at high risk of implementing restrictions.
For each foregone abortion, the researchers estimated an additional 0.8 births—a previously published conversion that accounts for some pregnant people miscarrying. With that conversion, the estimated additional births are then multiplied by state-specific pregnancy-related mortality rates to get the estimated increase in deaths. Generally, pregnant people living in states with abortion bans are three times more likely to die from pregnancy than pregnant people living in states without bans. And overall, the US has the highest pregnancy-related mortality rate among all high-income countries.
Last, the researchers estimated additional rates of health problems from certain pregnancy complications, namely ectopic pregnancy, previable premature rupture of membranes (PPROM), and preeclampsia. In the year since the Dobbs decision, health researchers have already documented increases in suffering and harms to pregnant people due to new restrictions delaying standard care, which exacerbate already life-threatening complications.
None of this is surprising. As Dr. Tedros Adhanom Ghebreyesus, director-general for the World Health Organization, said last year at the news of the Supreme Court's decision: "The evidence is irrefutable. Limiting access to safe abortion costs lives and has a major impact particularly on women from the poorest and most marginalized communities."
In all, Gaffney and colleagues estimated that there would be 30,440 fewer abortions in the 13 trigger-ban states as of March 30, 2023, with 76,612 fewer abortions if the additional 10 high-risk states enacted bans. The estimates boil down to an estimated six additional pregnancy-related deaths annually in the first scenario and 15 in the latter. Additional cases of postpartum hemorrhage were estimated to be 782 and 1,967 in the two scenarios, respectively. And morbidity around the time of birth would increase by 454 cases in the first scenario and 826 cases in the second.
Conclusions
In all, the researchers estimate that the three decisions combined could lead to around 3,000 deaths total in the coming decade if nothing else changes. The higher-end estimate, which the researchers note could be more realistic, would be nearly 6,000.
The estimates are considered conservative. For instance, OSHA estimated that its ETS would prevent 6,830 deaths. Yet neither estimate accounted for reduced transmission from the vaccination, masking, and testing the ETS would have required, which would likely also drive down deaths and severe illnesses.
For the Bruen decision, the researchers note that it's possible that reductions of firearm-related homicides could result in "substitutions" of homicides by other means, which could offset estimates for additional deaths. But, the researchers cite a 2020 meta-analysis suggesting that such substitution is negligible.
Last, there are several limitations to the estimates for abortion. Namely, the authors didn't account for deaths from self-managed, unsafe abortion in areas where it is now banned or restricted. Globally, 4.7 to 13.2 percent of all pregnancy-related deaths can be attributed to unsafe abortion, the World Health Organization reports. The estimates also didn’t account for delays in abortion care (from congested facilities or new restrictions), which can increase the risk of complications, nor did it assess the increased risk of poverty for people forced to continue pregnancies.
Still, the estimates make clear that the high court's decisions can have far-reaching effects on many aspects of Americans' lives, including their health. "The findings of this study suggest that these Supreme Court decisions may harm the health of US citizens for years, and possibly decades, to come."
