A Closer Look at the Uninsured
Why the "46 million" figure is profoundly misleading.


The American health-care debate is a blizzard of numbers, but few get tossed around as frequently as “46 million.” According to the Census Bureau’s Current Population Survey (CPS), that’s roughly how many people (the more precise figure was 45.7 million) lacked health insurance at a given moment in 2007 — nearly one-sixth of the entire U.S. population. The latest CPS data show that 46.3 million were uninsured at a given moment in 2008.   

Yet while it carries superficial appeal as a political talking point, the “46 million” statistic tells us nothing about the demographics of America’s uninsured. Economist Keith Hennessey, director of the National Economic Council under Pres. George W. Bush, has examined the 2007 data and sliced the 45.7 million uninsured into several distinct clusters, basing his estimates on an earlier government analysis, conducted in 2005. Hennessey reckons that 6.4 million were enrolled in Medicaid or the State Children’s Health Insurance Program — now known just as the Children’s Health Insurance Program (CHIP) — but misreported their status (a phenomenon known as the “Medicaid undercount”); 4.3 million were eligible for Medicaid or CHIP but not enrolled; 9.3 million were noncitizens; 10.1 million belonged to families earning more than 300 percent of the federal poverty level (FPL); and 5 million were childless adults aged 18 to 34. If we eliminate those individuals from the original 45.7 million, we are left with about 10.6 million.

After adjusting for the Medicaid undercount, Urban Institute researchers John Holahan, Allison Cook, and Lisa Dubay determined that in 2004, fully one-quarter of the nonelderly uninsured were eligible for Medicaid or CHIP, and another 19 percent belonged to families earning 300 percent or more of the FPL. Nearly three-quarters (74 percent) of uninsured children were eligible for Medicaid or CHIP (as were 28 percent of uninsured parents), and another 15 percent had family incomes equal to 300 percent or more of the FPL. This means that only 11 percent of uninsured children were both ineligible for government coverage and living in families with incomes below 300 percent of the FPL. These children — the 11 percent — were disproportionately Hispanic (42 percent), and the vast majority (77 percent) belonged to families earning between 200 and 299 percent of the FPL.

To be sure, estimates of how many Americans are “voluntarily” or “involuntarily” uninsured will fluctuate depending on methods and assumptions. The Urban Institute study — conducted for the Kaiser Commission on Medicaid and the Uninsured (KCMU) — designated 300 percent of the FPL as the affordability threshold for insurance coverage. Economists June and Dave O’Neill of Baruch College believe a more appropriate threshold is 250 percent. The O’Neills calculate that in 2006, roughly 43 percent of all uninsured individuals between the ages of 18 and 64 had family incomes greater than this level — and thus were “voluntarily uninsured,” because they appeared to have “enough disposable income to purchase health insurance.”

Whether we use 250 percent or 300 percent as the affordability line, those uninsured by necessity, rather than by choice, constitute a significantly smaller group than 46 million. Their numbers shrink even more when we remove noncitizens. A KCMU/Urban Institute analysis notes that in 2008, 20 percent of the nonelderly uninsured were not American citizens, and nearly half (46 percent) of all nonelderly noncitizens lacked health insurance.

President Obama seems aware that noncitizens represent a hefty chunk of the uninsured: In his September 9 speech to Congress, the president declared, “There are now more than 30 million American citizens who cannot get coverage” (emphasis added). According to White House budget chief Peter Orszag, Obama’s estimate excluded those uninsured citizens who are eligible for Medicaid or CHIP but not enrolled.

As these data confirm, the uninsured are hardly a monolithic bloc. For that matter, they are a highly fluid population: A 2003 Congressional Budget Office (CBO) report observed that “between half and two-thirds of the people who experienced a period of time without insurance in 1998 had coverage for other portions of the year.”

We must also distinguish between having health insurance and having access to health care itself. Based on data from the 2005 Medical Expenditure Panel Survey, the O’Neills reckon that when it comes to selected medical services received by Americans aged 18 to 64 — including routine checkups, blood-pressure checks, flu shots, Pap smears, PSA tests, and mammograms — “the uninsured receive about 50 to 60 percent of the amount of services received by those who are insured.”


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