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So, who ARE the remaining 33 million uninsured?

Last week, after the latest quarterly Gallup survey came out stating that the uninsured rate among U.S. adults had dropped to just 11.4%, I did some number-crunching and pointed out that:

  • When you take children into account as well, the rate across the entire U.S. population is likely down to around 10.3%
  • 10.3% of 320 million = around 33 million
  • About 6.5 million of those 33 million are undocumented immigrants who are therefore not eligible for coverage via the ACA anyway
  • Another 3.7 million are folks caught in the "Medicaid Gap" in 21 Republican-controlled states...these are people who a) make less than 100% of the federal poverty line (making them ineligible for federal tax credits to purchase private policies) but b) aren't eligible for traditional Medicaid either, meaning they're basically screwed.
  • When you subtract those two populations, it leaves roughly 22.8 million people who are still uninsured. So, who are they?

Well, according to the Kaiser Family Foundation, as of 2014, there were roughly 13.8 million uninsured eligible for Medicaid (either traditional or via ACA expansion). Since then, thanks to several more states going through with expanding the program (Pennsylvania, Indiana and, any day now, Montana), this number has increased to around 14.3 million. According to the March Medicaid report released by CMS in June, there's been a net increase of 12.2 million Medicaid/CHIP enrollees since 2013 (I'm not including the 950K "bulk transferees" brought onto the program prior to October 2013, since most of those were already covered by some other state-run program).

Of course, this number has likely increased by several hundred thousand since the end of March; my best guess is that it's up to over 13 million by now (again, not including bulk transferees). If so, that suggests that there could be as few as 1.3 million potential Medicaid/CHIP enrollees left to sign up.

However, it's also important to remember that due to the massive amount of churn in the healthcare market, some number of those 13 million who are new to Medicaid could have moved to the program from some other form of coverage. Some lost their job or otherwise fell on hard times. Pregnant low-income women become eligible during their pregnancy; once born, their child is eligible, and in many states the parents are still eligible as long as their child is, and so forth. This also, of course, ties in with general population growth, which skews the numbers somewhat as well.

How much do these (and other) factors pad the "uninsured eligible for Medicaid/CHIP" number? I don't know, but perhaps 3-4 million sounds about right to me. Let's call it 3.5 million for the moment; if so, that still leaves 19.3 million on the private policy side.

Again, according to my best analysis of the Kaiser Family Foundation's estimates, it looks like we started out with a total of roughly 12.6 million uninsured people eligible for federal tax credits via the ACA exchanges (ie, between 100-400% FPL), plus another 9.4 million who are uninsured but make too much to be eligible for tax credits (ie, more than 400% FPL). That's 22 million even. Of course, a big chunk of these groups has enrolled in private QHPs: Around 10.3 million are currently effectuated as of this summer.

According to the latest Commonwealth Fund survey, about 53% of the 11.7 million people who selected private 2015 policies via the exchanges are newly insured. Of course, as I just noted, due to non-payment and attrition, that total is down to around 10.3 million now. I have no idea whether that 53% has held proportionately among those still enrolled, but assuming it has, that means roughly 5.5 million of these folks are newly insured. Furthermore, around 85% of 2015 exchange QHP enrollees receive tax credits, or 4.7 million, with the other 800K coming from the "over 400%" crowd.

That should knock the uninsured populations down to something like:

  • 6.5 million: Undocumented Immigrants
  • 3.7 million: Medicaid Gap
  • 3.5 million: Eligible for Medicaid/CHIP
  • 7.9 million: Between 100-400% FPL (tax credits)
  • 8.6 million: Over 400% FPL

This still leaves around 2.8 million people unaccounted for. On the one hand, that's an awful lot of people. On the other hand, given all the estimates, rounding, population growth and churn swirling around as everyone's situation changes from month to month, that seems like a pretty good breakdown to me.

Thoughts?