Yes, Those Inflated Uninsured Numbers Really Are Inflated


Over at The New Republic, Anthony Wright strikes back against those of us (like me) who've cautioned against blindly accepting the 47-million-uninsured figure regularly tossed around by reform advocates. But in the course of doing so, it seems to me he very nearly makes the skeptic's case he's warning against. 

Wright begins by pointing out new Census data showing 46.5 million uninsured in 2008. He then notes that conservatives typically make a three-point case against the use of this statistic:

Critics make three arguments here: 1) the number includes immigrants; 2) the number includes people who are eligible but not enrolled for public health programs like Medicaid and SCHIP; and 3) the number includes people who make more than a certain income, and supposedly could "afford" coverage. 


In response to the first criticism he points to data showing that… there are more than one million illegals included in the uninsured count in California alone. That's 20 percent of California's uninsured population. Wright is almost certainly correct that the percentage is smaller nationally, but even if the percentage is, say, half that—10 percent—that still means that the 46.5 million uninsured number includes several million illegal immigrants—just as skeptics say. 

Next, Wright takes on the claim that a significant number of the uninsured are actually already eligible for government assistance through Medicaid or SCHIP. His response? "It's true that there are low-income family members who are eligible but not enrolled for an existing coverage programs." Yes, he also says that 1) there are still a large number of people who aren't eligible and 2) part of the reason that people who are eligible haven't signed up is that the forms are too complicated, and that health-care reform would simplify the process. 
Fair enough, but I don't see how this in any way proves the point made by skeptics wrong. Indeed, Peter Orszag, the administration's top health-care number cruncher, recently cited a report by the Kaiser Commission showing that, of the nation's 46 million uninsured, 11 million are already eligible for government assistance. 
Finally, he notes that, although there are indeed people who make $50,000, or even $75,000, a year who aren't insured, in some cases that's because health insurance is too expensive, and in other cases that's because they've been denied preexisting coverage. Again, true enough, but I'm not sure how this rebuts the original point that some significant number of the uninsured probably make enough money to purchase insurance but choose not to. Given that Census data indicates that nearly 18 million of the uninsured make more than $50,000 a year, and of that group, about 9.7 million make more than $75,000, it seems entirely reasonable to assume that several million people in the country could currently afford health insurance and simply choose not to purchase it. 
I'd add a fourth criticism as well, one that Wright also implicitly backs up: Not all of the uninsured are chronically uninsured. Instead, they're out of insurance for a day, or a week, or a few months (as I was earlier this year), typically when switching jobs. The fact that insurance is tied to employment certainly makes it more difficult for some of these people to get insurance, but to my mind, these individuals are not necessarily a sign that we're in crisis. Wright, on the other hand, thinks reform advocates ought to use the temporarily uninsured to expand the number of uninsured even further by including people who've been briefly uninsured over the last two years rather than one. 
That's because Wright's larger point is that it's better "not to think of the uninsured as a discrete population, one that can be marginalized," but instead "to think of uninsurance as a condition that can afflict anyone." Basically, he says, we should ignore the way the numbers actually break down and think of being without insurance as a wild predator that randomly attacks individuals for no reason whatsoever. 
Problem is, there are reasons people are uninsured—they don't bother signing up for assistance, they make too much money, they're in between jobs, etc. It's not random, and for many of those individuals, it may be possible to address the specific reasons rather force everyone into a one-size-fits-all mandatory insurance scheme. None of this is to deny that the current system is a terrible mess. But I do think the reform proposals floating through Washington right now will only make it messier.
More than that, it's perfectly reasonable to attack the inflated uninsured stat employed by reform advocates. Yes, millions of those people do have trouble getting insurance, and that shouldn't be ignored. But millions of them aren't chronically uninsured, do have options to get coverage, and don't really fit into the reformers' nation-in-crisis narrative. 
Read Reason's health-care archive here.  

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  1. Re Medicaid and SCHIP: part of the reason that people who are eligible haven't signed up is that the forms are too complicated, and that health-care reform would simplify the process.

    Ha! This is the same sort of idiotic argument that says we're going to fund universal care with the billions in savings we get by cutting waste and fraud from Medicare. If there's billions in savings to be had, why not get them now? If the forms are too complicated, why not simplify them now? Why do all these fixes need to wait until 2013 when the OMG-gotta-have-it-right-now healthcare reform is supposed to kick in?

  2. It's a crisis, dammit!

  3. I agree with your assessment, but find it somewhat derogatory to call people "illegals," rather than "illegal immigrants."

  4. Preemptive shut the fuck up, Lonewacko.

  5. Adina,

    I'm not an immigration restrictionist by any stretch, but I tend to think disputes over terminology get silly pretty fast: Whether or not you like current immigration law (I don't), they're here illegally, which makes them all illegal, which makes them, collectively, illegals. I don't intend it as an insult in any way, just as a short descriptor.

  6. When is H&R gonna post a rebuttal to the scathing attack on Ayn Rand and the philosophy of wealth-makes-right I just read at TNR?

  7. As PapayaSF points out, one of the fishy things about this health care reform effort is the revolutionary attitude Obama and his crew are taking. Instead of pointing out discrete minor problems that affect 5 or 10 million people here and there and solving these problems one by one with a modest piece of legislation (one small enough people might actually read it), Obama wants to revolutionize the entire health care system. Why does it have to be all or nothing? Why not a series of piecemeal reforms that each attack easily identified problems?

  8. mitch,

    Piecemeal reforms is all that is being proposed. The legislation could consist entirely of subsidizing one doctor to treat a single case of crabs and the opponents would still be screaming hysterically about teh soshulism.

  9. Why does it have to be all or nothing? Why not a series of piecemeal reforms that each attack easily identified problems?

    What? You've never heard of LBJ's Skirmish on Inadequate Weekly Allowences?

    Me neither.

  10. I suspect that by Tony's standards, the New Deal and the Great Leap Forward were also "piecemeal reforms."

  11. I suspect that by Tony's standards, the New Deal and the Great Leap Forward were also "piecemeal reforms."

    Of course they were. Capitalism is still in place and there were survivors of the Great Leap. Oh, and of FDR too.

    Give it time.

  12. Memo to Reason: please try and keep up. I commented on the new CB numbers four days ago, and in that post I pointed out that I'd posted about 2007's numbers about a year ago. In the earlier post, I warned people to "watch for liars" about those numbers.

    Would a time machine help Reason?

  13. the philosophy of wealth-makes-right

    As opposed to the philosophy "my-want-gives-me-the-right-to-enslave".

    You better get to this fight early folks, because it's really not going to last long.

    So let's suppose, just for a moment, that the 47 million uninsured number was anywhere near valid. This still represents a clear democratic minority. By the rules and principles of democracy, even a 51% majority has the right to say "tough shit" to a 49% minority. And 47 million is way less than a 49% minority.

    The End Tony.

  14. part of the reason that people who are eligible haven't signed up is that the forms are too complicated, and that health-care reform would simplify the process.

    No, actually those too stupid to properly fill out forms would continue to fall thru the holes in the safety net just as they do everywhere.

    But it won't matter. The pressure for universal health care isn't about the poor, it's about protecting the assets of the "middle class". Once they get theirs, the "poor" will be forgotten.

  15. Yes. But who defines "middle class"?

    Whoever they are, once they get theirs, the "rich" will be forgotten as surely as the "poor".

  16. "Ayn Rand and the philosophy of wealth-makes-right I just read at TNR?"

    I haven't read this article, and have minimal intention of doing so - but Ayn Rand's philosophy wasn't remotely "wealth-makes-right", so... Umm... They're not off to a good start.

  17. Remember folks, it's always about the 'narrative'.... if it doesn't fit into it, they'll distort and contort to make it so or just ignore and deny it altogether.

    That's quite irrational.

  18. When was the debate renamed? Isn't this a bunch of proposals and a few bills in Congress to reform health "insurance"? Why do you all accept the change to reform health "care"? Besides, you are all missing the point of it. Where is a bill in Congress with real Congresscritters signed on as sponsors and all that, which bill contains anything that President Obama said? That contains anything that he "promised" or that he "pledged"? Hello? No such bill exists nor will it ever. The Democrats are going to pass whichever version of the pending House bills they prefer and then get into a conference committee with the Senate and the Democrats will pass a health "care" reform bill that they can agree upon. Republicans are not invited to the clambake. Blue Dogs will be offered the carrot - vote for it and we'll help you get re-elected and here's some pork; and the stick - vote against it or abstain and we'll fund your primary opponent. And enough of them will fold over. And at the '10 elections, enough "community action" groups will get the dead, insane and incarcerated felon vote out to win in any doubtful district. It isn't about health care or health insurance. It IS about who controls the country, about who controls the Federal government, about how big are we going to grow the Federal government during THIS crisis and what can we whip up for our next crisis to expand it some more.

    You are all fussing about the quality of the music while the opera house is burning down around you. The objectives of President Obama and his Democrats is simple: (1) make sure we get re-elected; (2) make our jobs more important, more powerful and less accountable to anyone. Nothing else, all the rest is smoke and mirrors to disguise the genuine goals of this administration and its supporters.

  19. part of the reason that people who are eligible haven't signed up is that the forms are too complicated

    There will always be people who do not even have the responsibility required to sign up for free government stuff. I have seen it before. The entitlement attitude means that they don't think they should do anything at all, not even go to an office and fill out a form, to get the benefit.

    If these people won't put forth the effort required to fill out a difficult form I see no reason why I should have my hard earned money diverted to help them.

    The hard truth is that there is no way for government to force all people to be responsible, even with their own families. There are always those who simply will not participate if it means having to do anything. I say let them have their choice. Well, no, actually I say they will have their choice whatever the bureaucrats do - there will always be some form they can refuse to fill out.

  20. I thought under a federal statute called COBRA that people who leave employment for any reason have a right to continue their health insurance, at their own expense, for an extended period of time. I also understand that if you continue that coverage at your own expense, that when you get another job you will also be covered for "preexisting" illnesses because there was no break in coverage. So losing your job does not mean you automatically lose your health insurance. I realize that there may be exceptions to this, but I always read about people losing coverage due to employment reasons with no mention of COBRA rights, so I think this is another way the problem is overstated.

  21. People eligible for Medicaid are ALREADY INSURED.

    If they get sick or hurt, they go to the hospital. They get care. The hospital signs them up for Medicaid and bills Medicaid for their care.

    Medicaid is already acting as insurance for them whether they've signed up or not.

    Including these people in the 47 million makes the number deceitful, not just inflated.

  22. It is extraordinary how liberals assume that the services are desperately needed, yet not so much as to do what is necessary to get the free benefit. They don't understand how there is no way government can overcome a lack of personal responsibility.

    They will have free medical care - but will they go to the doctor? Will they follow the doctor's orders? Will they take their medicine? Will they give it to their children when they are supposed to?

    Why do we assume they will, if they will not even fill out a form to get these benefits? The problem is not lack of medical care. The problem is lack of responsibility.

    Next we will be taxed to hire someone to make sure they get their medicine.

  23. Most company plans allow for pre-existing conditions after 3 months ... so if you take COBRA and continue it for 3 months into your new job you can cover any pre-existing condition ...
    If you have a condition that still allows you to work its not the end of the world to pay for COBRA coverage. Yes a small % of people will not be able to afford it ... life is hard, wear a helmet ...

  24. When I offered health insurance to a 24 year old employee she said she'd rather use the money for a new car.

    Under the Obama plan she will be forced to buy health insurance she probably won't use for years to subsidize the costs for other people.

    Socialism: we give up what we want for what others want...

  25. "Next we will be taxed to hire someone to make sure they get their medicine."

    Ah geez! Don't give them any ideas. Damn.

  26. COBRA continuity has nothing to do with an exemption from pre-existing condition underwriting at the time of a new job.

    Many group plans have negotiated such an exemption, while bearing the pooled cost of coverage as a company. Underwriting still takes place, but rather than amounting to an exclusion for pre-existing conditions, it affects prices at the corporate level -- raising rates on all employees.

    The Democrats have only had the upper hand on this issue because of rank ignorance among the citizenry about how insurance markets operate.

  27. I agree with your assessment, but find it somewhat derogatory to call people "illegals," rather than "illegal immigrants."

    Wetbacks it is then.

  28. "I'm not an immigration restrictionist by any stretch .."

    Why the hall not? I'm losing patience with the so-called libertarians and conservatives who are defacto supporters of socialism. And sometimes more than defacto.

  29. A quick comment on difficult forms. This is not a bug, it's a feature. We recently moved into a new state and my wife has been attempting for nearly a year to secure respite care for our autistic son.

    Although we aren't eligible for or trying to get any income-based services (eligibility is supposedly based solely on our son's diagnosis), my wife and our son's doctors have had to fill out an astonishing variety of forms, including Medicaid applications, and have had them all repeatedly rejected and sent back for yet more information either not asked for the time before, not remotely relevant, or in fact previously provided. Calls and meetings invariably end up at the desk of yet another bureaucrat who has never read any of the file and requires my wife to start everything all over.

    I think it is reasonable to assume that my wife, a writer, is somewhat better educated that the average Medicaid applicant and capable of deciphering forms, yet we remain unable to penetrate the system. We assume that this is in part a very deliberate to make it as difficult as possible in order to save money; it certainly has that result in any case. So I sympathize with claims that many of those eligible don't get services because of the forms, and the process, and not because they are morons. But how exactly is this an argument that placing these same bureaucrats in charge of our entire healthcare system is going to be better?

  30. There's also the people who don't buy insuance because they need the money to pay the health care bills that insurance won't cover.

    That's not a contradiction. Working with developmentally disabled children, especially autistics, I've seen many families who were shocked to discover that effective therapy cost several thousand dollars a month but their insurance would max out at $4-5K a YEAR for such services. That leaves them with the choice of paying several hundred a month for insurance that does not cover their most pressing need, or putting that money towards therapies that they DO need.

    Likewise, a lower-income diabetic whose insulin and such are not covered as a "pre-existing condition" may well choose to opt out of insurance in order to afford their medications. There are countless other examples.

  31. What I don't get is the "14,000-a-day" losing their health insurance. I have read that it is based on some unemplyment studies made at the end of last year. But if it is true on a continuing basis, then the uninsured number goes up at a rate of 5.1 million per year, which means the "47 million" has increased to 48.3 million, just since mid-June, near when the Skip Gates "Health Care" news conference occurred. If true, the "14,000-a-day" should be far more alarming than the "47 million". Do I just miss it or does no one seem to challenge Obama very hard on that particular asserion? And even if it's partially true, I bet it leaves out the several-to-many thousands a day that I bet **gain** health insurance, or get born into health insurance, etc... Maybe it even includes many thousands who die each day and by definition, **lose** their health insurance!

  32. When you take out people who can easily afford insurance, people who aren't citizens, people eligible for Medicaid, and people who don't want insurance, is about 6 million

    That's right, this "crisis" is about two percent of Americans.

    We could solve this with a modest expansion of Medcaid. We don't need to trash 1/5th of the economy.

  33. Why does Medicaid have to be so complicated? The entire set of eligibility rules for food stamps fits on one somewhat-long Web page:

  34. The problems with our health care are myriad. It is not only trial lawyers, it is not only drug companies, it is not only Medicare/Medicaid and it is not only illegal immigrants. It is a lot of these factors. A point of clarification for COBRA. If I lose my job, I will need about $1,200 per month to pay for insurance through COBRA. Most unemployed people aren't going to be able to cover this and all their other living expenses. My husband has a chronic autoimmune disease. At current prices between medications, tests, and doctors, it costs about $100K annually for his care. We are fortunate to be in a group plan paid primarily by my employer, but we still have to pay a lot out of pocket. I'm against a gooberment takeover of healthcare, but the free market without some mandates, will never choose to cover people who are expensive to treat. Healthcare does need reform, but not the insane takeover that is being proposed.

  35. "I agree with your assessment, but find it somewhat derogatory to call people "illegals," rather than "illegal immigrants."

    Agreed Adina. Criminals should be treated with more respect.

    "The problems with our health care are myriad. It is not only trial lawyers, it is not only drug companies."

    Right Daisy. Lets put those evil drug companies out of business. Better yet, lets force them to to gamble their stockholders' equity on new drugs and pocket the profits for ourselves. Everything will be so much better.

  36. And let's not forget that the Census Bureau's categories (that get totalled to = about 47 million), do not appear to be mutually exclusive! I don't know if it's even possible to estimate the amount of double/triple-counting that might be going on in that 47 million total.

  37. willis. Thanks - way to act like a fool and make up stuff I didn't say. AND, just in case you didn't catch it - I think I'm mostly on your side. I didn't call drug companies evil, but I do have a problem with a lot of the things they do. Many of them also receive government (taxpayer) subsidies to do R & D, so don't whine to me about the risks they take. They also seem to be in bed with the FDA in getting drugs that kill people pushed through the approval process with not enough testing having been done. It certainly appears that this often coincides with patents that are about to expire.... WAKE UP! Our government is controlled by special interests on both sides of the aisle. They are in bed with big business - they are not interested in protecting anyone's rights.

  38. I have a much easier time filling out insurance forms than I ever do any sort of government form. even some of the half page forms have so much legal gobbledygook that even my attorney father has trouble figuring out what the hell it means.

  39. "COBRA continuity has nothing to do with an exemption from pre-existing condition underwriting at the time of a new job."

    It can. Some policies waive a waiting period for coverage of a preexisting condition, if and only if the policyholder has had continuous coverage for the previous X amount of time.

    Again, this is not a huge deal for most people, but it is a fairly common clause, I believe. And if it's a huge deal for YOU at a given point in time, I suppose you don't care about "most people."

    "Healthcare does need reform, but not the insane takeover that is being proposed."

    Hear, hear.

  40. "COBRA continuity has nothing to do with an exemption from pre-existing condition underwriting at the time of a new job."

    What we need is a czar for these situations, a "COBRA Commander" if you will.

  41. The prohibition against pre-existing condition restrictions for the previously insured who are changing jobs is in the HIPAA act. COBRA's of relevance only as a trigger for some aspects of HIPAA.

  42. Under HIPPAA, which has just been the law for a decade, there can be no preexisting condition restriction unless there has been a break in coverage (including COBRA coverage) for at least 63 days.

    In fact, if you follow the link you will see that the preexisting condition argument is mostly bogus. The worst that can happen is that, if you sought treatment for a condition in the 6 months prior to applying for insurance, you can be excluded for coverage for that condition for no more than 18 months, while getting coverage for anything else.

    Now, combine this with the fact that the census bureau says that it's figures understate insurance coverage because it asks, in April, about whether people were covered at all the previous year. In fact, people don't really remember the detail of last year's insurance coverage all that well and tend just to answer based on whether they have insurance at the time the question is asked. (The Census Bureau's explanation of this can be found on page 59 of this slow-loading pdf.)

  43. Amphipolis | September 15, 2009, 9:22am | #

    "There will always be people who do not even have the responsibility required to sign up for free government stuff."

    In this case, it's not even irresponsible. If you're eligible, you can sign up AFTER you get sick... So its just being smart? might as well put off the big hassle of signing up for government medical coverage unless you need it.

    Also (re: unrelated) these 47 million figures usually also include those eligble for medicare... you can see if if they break down the figure by age somewhere.

  44. Ken Hennessey has done a very careful analysis.


    He comes up with a 10.6 million who are
    " * U.S. citizens;
    * with income below 300% of poverty;
    * not on or eligible for a taxpayer-subsidized health insurance program;
    * and not a childless adult between age 18 and 34."

    Wasn't it interesting that Obama usually speaks of 47 million who are uninsured. But early in his speech [before Joe Wilson's shout about illegal immigrants] the president used the number "33 million uninsured Americans." Hennessey estimates "9.3 million of the 47 million are non-citizens."

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