Counting the Uninsured

By September 23, 2009November 2nd, 2009Commentary

One of the drivers of health reform has been the number of persons without health insurance, typically stated as 45 million or more.  While doubt has frequently been cast upon that number, a recent study indicates that the number of persons served by Medicaid has certainly been undercounted and therefore the number of uninsured overstated.  (Health Affairs Article) Estimates of health care coverage of various types is generally derived from census surveys.  The survey results on Medicaid coverage have long been at odds with numbers reported by CMS.  The study authors suggest that this results from the nature of the census questions and people’s difficulty in recalling details of their insurance coverage.

It appears that Medicaid enrollment has been understated by several million.  The study also suggests that a similar undercounting might exist for private insurance.  The 45 million number has many problems, such as inclusion of 9 million illegal immigrants whom most policy-makers seem to agree will not get coverage under any reform.  There are a large number of people eligible for Medicaid who never enroll in it, presumably because they are either unaware of their eligibility (doubtful since providers would be highly incented to make sure a patient knows they could have Medicaid coverage) or simply don’t believe they will need medical services.  These people get counted as uninsured.  Even Medicare apparently has as many as a million eligibles who don’t enroll.  And there is a large block of citizens who appear to have the income to afford insurance but decide not to buy it, one would imagine because they don’t believe they will have extensive need for medical care or they would rather pay out-of-pocket.

It becomes difficult to use the presence of a large contingent of uninsured persons as a rationale for reform, especially urgent reform, when the numbers are so untrustworthy.  On the other hand, there do appear to be serious cost issues, so perhaps the focus for now should be on cost control, not increasing access to coverage.

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