No, 20 Million Haven't "Gained Coverage" Under Obamacare


A report in the New England Journal of Medicine tallies up the various ways that Obamacare has expanded health insurance coverage and estimates that a total of 20 million people have "gained coverage under the ACA" as of May 1. It's a count of people obtaining coverage, whether or not they had it before, not people who were previously uninsured, and it's meant to suggest the sweep of Obamacare's impact following its first enrollment period. But the sources used for this tally don't offer the kind of precision necessary to be confident in the headline estimate. It's not possible to pin down the exact number of people covered because of the law, but this figure is almost certainly overstated.

New England Journal of Medicine

Here's the graph showing where the figures come from.

Let's start with the 1 million young adults. That number is related to Obamacare's requirement that insurers carry adult dependents up to age 26, and it's lower than the 3 million the administration has long claimed from that provision, based cherry picked year-to-year comparisons. The 1 million figure is within the realm of plausibility, but it still might be high. As Avik Roy of the Manhattan Institute has noted, the only way you get to roughly one million here is if you credit Obamacare's requirement for essentially the entire recent expansion of coverage amongst young adults. So, sure, a million is possible—but it's also possible that the number is quite a bit smaller.

The next figure, which adds 8 million marketplace sign-ups into the mix, comes from the administration's reporting on how many people have signed up for private coverage through the law's health exchanges. But as the authors note in the article, that figure doesn't account for people who signed up and didn't pay, which, based on government and insurance industry estimates, will likely cut 10 to 15 percent from the total. That would bring the total closer to 7 million (and that ignores the potential for attrition due to non-payment in later months).

The article also count 5 million covered via purchase directly from an insurer—that is, people who bought individual insurance, but not through the law's exchanges. As The Washington Post's Glenn Kessler pointed out recently when examining a similar coverage claim from the administration, these plans are not an obvious choice for inclusion: 

Off-market plans are sold directly by insurance brokers or insurance companies, meaning they generally do not qualify for Obamacare subsidies. (An insurance agent could help someone enroll on an exchange if they have proper certification.) But off-market plans do include the protections included in the law, such as guaranteed coverage for people with preexisting conditions and a package of essential benefits.

Still, CBO calculated that the number of off-exchange plans would drop from about 10 million to 5 million as people moved to buying insurance on the exchanges. So why should she tout a figure that was due to go down because of the law, especially because she said she was talking about people with "affordable coverage"?

Finally, the graph cites 6 million enrollments in Medicaid or CHIP (the Children's Health Insurance Program). That number presumably comes from a June administration report stating that, nationwide, Medicaid enrollment has increased by 6 million following Obamacare's open enrollment period. But this number, too, likely overstates Obamacare's direct effect on the expansion.

For one thing, it includes people who were previously eligible for Medicaid, and merely signed up after October. For another, as the authors note in the article, it includes people in states that did not expand Medicaid under Obamacare (although the administration reports that sign-ups rose much faster, at a rate of 15.3 percent, in states that participated in the expansion, compared with 3.3 percent in non-expansion states). The administration's report also says that states are still reporting Medicaid figures in a variety of different ways, and thus cautions that this "limits the conclusions that can be drawn from the data." Even the administration does not seem to want to claim the entire 6 million: "It is important to note that multiple factors contribute to the change in enrollment between April 2014 and the July-September 2013 baseline period," the report says, "including but not limited to changes attributable to the Affordable Care Act." Obamacare was part of the story—but not all of it.

It seems clear that millions of people, some of whom were previously insured and many who were not, did in fact obtain health coverage through Obamacare's various coverage-expanding provisions. But it's too early to say exactly how many so far—only that 20 million is almost certainly an overstatement.

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  1. So, to run the numbers with less blah-blah:

    (1) 1mm “young adults” is way high, as it doesn’t deduct those young ‘uns who would have gotten insurance at work if they didn’t get a better deal at home. Call it 500,000 (why not? its as good a guess as any).

    (2) 7mm on the exchanges. Ok, sure.

    (3) 5mm on off-exchange policies. No reason at all to think that these policies wouldn’t have been sold absent ObamaCare. Sure, the benefits are different, but so what? We’re counting policies sold here. So, dump that number.

    (4) 5mm people lost coverage in December due to ObamaCare. The off-exchange market has also shrunk by 5mm. I don’t know how to avoid double-counting here, so we’ll just say 5mm fewer off-exchange policies should be deducted from the total.

    I get a net gain of 2.5mm, and I think that’s the upper bound. Account for non-payment and the full loss of off-exchange coverage, and I suspect it could get perilously close to zero.

    Oh, and Medicaid expansion? Not insurance. Don’t count it as such.

    1. Account for non-payment and the full loss of off-exchange coverage, and I suspect it could get perilously close to zero.

      Not to mention that the ‘gaining of coverage’ is neither a necessarily desirable means nor the ends.

    2. “Oh, and Medicaid expansion? Not insurance. Don’t count it as such.”

      Obama couldn’t have expanded Medicaid the way he did without ObamaCare though.

      Compensating for all the losses providers suffer for treating Medicaid patients is a huge part of the problem.

      Show me an inner city hospital that’s closed over the last 25 years, and I’ll show you a hospital serving a demographic pool with a disproportionately high number of Medicaid patients.

      Medicaid couldn’t go on the way its been without some kind of major reform. It’s just that my idea of reforming Medicaid doesn’t include siccing the IRS on the working poor, creating novel constitutional arguments about eating broccoli, or forcing middle class America to accept lower quality healthcare for higher premiums and higher deductibles.

      Obama could have sent every adult Medicaid patient a check good only for the purchase of private insurance, and it would have been a better reform than this. Unfortunately, Obama has nothing but contempt for the poor and their ability to make choices for themselves. …unfortunately for the poor, that is.

      1. Sure, sure. My point is that any talk of increase in insurance coverage should not include Medicaid. Medicaid is welfare, not insurance.

        You might as well call food stamp cards “paychecks”.

  2. Even taking that 20M figure, at $183B per year, that’s over $9,000 per person covered. That’s insane.

    1. We’re essentially paying twice for coverage: once for the bureaucracy via taxes, and again for the policy via premiums.


      1. Twice is pretty much right. The average individual employer-based insurance premium in the US in 2010 was $4,940. http://www.ncsl.org/research/h…..miums.aspx

        Obamacare manages to spend nearly twice as much per covered person and still doesn’t cover 100% of premium costs.

        1. And that doesn’t include skyrocketing deductibles.

          “The average individual deductible for a bronze plan is a whopping $5,081 per year, according to research provided to CBS MoneyWatch from HealthPocket, a technology company that ranks health care plans.

          What’s worse, that represents an increase of 40 percent from the average deductible for an individually purchased plan before the federal health care overhaul, according to The Wall Street Journal.”


          Can you imagine working poor people finding out that although they have insurance–for the first time (according to Obama)–they still have to shell out thousands of dollars before the insurance kicks in, in addition to the premiums they’re paying?

          And how much better is the middle class off–having to pay 40% more in deductibles?

        2. You do realize that the figure you cite is the employee contribution, not the total cost, right?

          Specifically, from this same source, “Annual premiums for employer-sponsored family health coverage reached $16,351 this year, up 4 percent from last year, with workers on average paying $4,565 toward the cost of their coverage, “

          1. Unfortunately, the 16k is for family. The 4.9 k value is for individuals.

            What’s the source for the $183B/year though?

    2. Where does $183B/year come from?

  3. The problem with Obamacare and with single-payer systems in general has and always will be the quality and cost of care, not the availability. Prior to O’care, hospitals were legally required to treat emergency patients. All O’care has done is require insurance companies to ignore pre-existing conditions and provide one-size-fits-all policies, effectively shooting the concept of a risk pool and creating a scenario where health costs will rise for everyone. More people are now eligible for Medicaid, which is handy because fewer people will be able to afford insurance premiums, which are rising because of the inability of insurance providers to assess premiums based on risk or provide limited coverage.

    O’care was never intended to reduce health insurance premiums, because if that was the idea it would have eliminated the legal barrier to interstate health insurance. It wasn’t meant to reduce health care costs–which have risen–because it has done nothing to, for instance, address malpractice lawsuit damages, Medicare/Medicaid reimbursements, or FDA rules regarding pharmaceuticals and procedures. It’s a typically Progressive law: it attempts to use the coercive power of the state to force people to behave in ways certified by a committee of Top Men to be beneficial, regardless of how that might mesh with facts or individual rights.

    1. It wasn’t meant to reduce health care costs–which have risen–because it has done nothing to, for instance, address malpractice lawsuit damages, Medicare/Medicaid reimbursements, or FDA rules regarding pharmaceuticals and procedures.

      Not to mention the fact that, save for a few cash-only practices, it’s nearly impossible to find out what a medical service costs beforehand, which reduces competition between service providers. I suspect that people would still be willing to pay a little more for a doctor with a good reputation, but it’s been demonstrated before that a cash-based payment system can lower costs by 50-80 percent, especially if you know what you’re paying beforehand.

  4. The problem with Obamacare and with single-payer systems in general has and always will be the quality and cost of care, not the availability.

    Oh, I think availability is a huge problem with single-payer systems. Waiting for care, beyond a point, is denial of care. And they all make you wait.

  5. Obamacare did solve the problem of that nasty brown ring in my toilet.

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