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Who is left uninsured by the health-care reform bill?


The graph atop this post shows the predicted insurance situation (numbers come from this CBO report) for non-elderly Americans if health-care reform didn't pass. It's not a pretty graph, but it'll do the trick. You're seeing 162 million people in the employer market, 54 million uninsured, 35 million people on Medicaid or the Children's Health Insurance Program, and 30 million people in the non-group/other market (this contains not just the individual market but small public plans). To put that slightly differently: No insurance is predicted to be the second-most common arrangement. Compare that to the post-reform prediction:


Here you're seeing 159 million Americans on the employer market, 44 million on Medicaid or the Children's Health Insurance Program, 25 million on the non-group/other market, 24 million in the exchanges, and 22 million left uninsured. The uninsured category has gone from the second largest to the absolute smallest. And though there's no public option, there are a lot more people eligible for public programs. But all in all, only 40 million Americans are in a different insurance situation than would otherwise have been the case. Three-quarters of them would've been otherwise uninsured, and a few more would've been on the individual markets or getting insurance through a small business who's now using the exchange.

But some of you have asked why there's an uninsured category at all. There are a couple of reasons. About a third of the remaining uninsured are illegal immigrants, who are ineligible for coverage through the program. Then there are some folks who have incomes below the individual mandate threshold. Under the terms of the individual mandate, if coverage would cost more than 8 percent of their monthly income, they can skip it. Other people will decide to pay the individual mandate's $750 penalty rather than purchase insurance. Still others will be eligible for public programs such as Medicaid but won't sign up.

So the population of the uninsured will be far reduced, and primarily composed of illegal immigrants, the few people who can't afford their insurance and aren't getting subsidies to help them purchase it, and people who have decided to pay the penalty rather than purchase insurance.

By Ezra Klein  |  March 22, 2010; 3:29 PM ET
Categories:  Explaining health-care reform  
Save & Share:  Send E-mail   Facebook   Twitter   Digg   Yahoo Buzz   StumbleUpon   Technorati   Google Buzz   Previous: Will insurers raise rates before health-care reform?
Next: An interview with Kaiser's Drew Altman


So how would a comprehensive immigration reform bill that say, legalized almost all illegal immigrants by 2014 impact this whole equation? Would they weigh too heavily on the subsidies or would it be manageable?

Posted by: Owen_Truesdell | March 22, 2010 3:37 PM | Report abuse

@OT: Immigrants tend to be younger and healthier, so they should make the risk pool more attractive to insurers. As for the subsidies, I am guessing that they will be neutral w/some qualifying, some not, and some paying the fine instead of buying more expensive insurance. If they are at the low end of the income scale, they would qualify for medicaid.

Posted by: srw3 | March 22, 2010 3:45 PM | Report abuse

So please explain the distinction between the Individual Market and the Exchanges. I had thought everyone would have to buy insurance through the exchanges.

Posted by: BobN1 | March 22, 2010 3:47 PM | Report abuse

I believe that should be "About a TWO-THIRDS of the remaining uninsured are illegal immigrants"

Posted by: danwhalen2 | March 22, 2010 3:52 PM | Report abuse

In other news:

The first post-apocalypse trading day ends. Stocks are up. Gold is down.

Posted by: luko | March 22, 2010 4:01 PM | Report abuse

Ezra: thanks for the good reportage. I was just about to email you with the very question of who's covered, when you wrote this post. I have a follow up question: You write, "Under the terms of the individual mandate, if coverage would cost more than 8 percent of their monthly income, they can skip it." Under WHAT terms might this happen, such that these people wouldn't already be covered by Medicaid?

Posted by: voxcivitatis | March 22, 2010 4:02 PM | Report abuse

Maybe throw some percentages atop those pretty colors? Doing so would make it even easier for us to remember.

Posted by: slag | March 22, 2010 4:07 PM | Report abuse

There seem to be a lot of commentators saying a lot of people will just do the math and pay the penalty. Can you give an overview of how the CBO projected the expected number of such cases?

Posted by: jeirvine | March 22, 2010 4:21 PM | Report abuse

Mr. Klein: "Other people will decide to pay the individual mandate's $750 penalty rather than purchase insurance."

$750 per WHAT? Per year? Per month? Every two weeks?

I sure don't know and it would seem to make a big difference.

-- MrJM

Posted by: MrJM | March 22, 2010 4:28 PM | Report abuse

Ezra - I'm an MD and I've followed your blog here for the last 6 months - please answer me a couple of questions/concerns. First off, I am happy reform passed. Imperfect, but sets us on a better path.

I am strongly in favor of disassociating employment and health care. I would much prefer everyone be required to make this decision on their own, via the exchange, which I think will provide better competition, higher quality etc. However, through this model, employer sponsered health care will acutally be higher. Do you think employer supponsered health insurance should go away? How do you go about doing this?

Second, I don't like how the exchanges are state run versus a national exchange. I think we will wind up with 50 different standards. Can we at least move towards regional exchanges with the current bill? Do you think states will do this?

Posted by: bennettcurtis | March 22, 2010 4:31 PM | Report abuse

Great post, Ezra. The American people do not agree with this bill. Another site represented this visually as well -

Posted by: michael431 | March 22, 2010 4:32 PM | Report abuse

How hard will it be for people to actually get the subsidies?

You postulate a residual category of uninsured "eligible for Medicaid but won't sign up." I assume those are mostly people who can't figure out or imagine figuring out how to negotiate the bureaucratic maze to get covered.

The same sort of people won't get the benefit of the subsidies unless it is very easy for them to be enrolled (or whatever it takes.) Folks who are at ease on the web and in contemporary society generally have little idea how daunting simple tasks can be for citizens who simply can't navigate the maze so easily. Think of the millions of children eligible but not enrolled in CHIP.

Those are some of my largest concerns about this. It's all very well to say there are subsidies, but will people really be able to access them?

Posted by: janinsanfran | March 22, 2010 4:39 PM | Report abuse

These people who claim to speak for the American people remind me very much of those who claim to speak for God...very hard to verify.
Some keep beating the drum that the American people don't want this bill -- which American people - the uninsured ones? Or just the covered ones. The rich ones?
What poop.

Posted by: bgreen2224 | March 22, 2010 4:45 PM | Report abuse

Ezra: Could you explain how the employer aspect of this works? The employer size, which employees are eligible for the exchanges, and penalties to the employer

Posted by: robie248 | March 22, 2010 4:46 PM | Report abuse


Can you explain the population figures cited in this blog post.

For the top chart, the numbers add up to 281 million people in the U.S. in 2018; for the bottom chart, 274 million. I presume the CBO has NOT concluded that our population will be 7 million less with healthcare reform, so what's up? Further, our population is now approximately 303 million, so there are at least 20 million people--with ZERO population growth in the next decade--unaccounted for in the post.

Posted by: DKB1 | March 22, 2010 4:50 PM | Report abuse

The results of this health care decision will be horrible.

Posted by: servant119b | March 22, 2010 4:54 PM | Report abuse

Who won't get insurance?

"the few people who can't afford their insurance and aren't getting subsidies to help them purchase it"

Since when did 10+ million people equate "the few."

I see we are getting some serious damage control and revisionism going on already.

What I see with "the few" is a permanent underclass who are being sacrificed in order to preserve tax subsidies for employer-provided health care.

Posted by: jc263field | March 22, 2010 4:54 PM | Report abuse

Nice charts but there is a segment missing - those who will be covered by a public option, probably through expanded Medicare for those under the age of 65. Four years (2010 to 2014) is a long time to be at the not-so-tender mercies of health insurers and it's a given that they will be devising ways to maximize profits before competitive pressure via the exchanges come into play. As Anthem in California demonstrated, health insurers will raise rates even in the face of tremendously negative public opinion. Double-digit increases in health insurance premiums between now and 2014 will lead to renewed calls for and the eventual enactment of a public option.

Posted by: tebrom50 | March 22, 2010 5:03 PM | Report abuse

In addition, even with the loss-ratio provisions in the new law, does anyone expect health insurers to book less profits between 2010 and 2014? Time to read some Wall Street analyst reports on the health insurers. The non-profit insurers will follow in their footsteps (if not lead) their for-profit brethren.

Posted by: tebrom50 | March 22, 2010 5:11 PM | Report abuse

What's the "other non-group" share in the second graph? I would have thought that would all (or almost all) have moved into the exchanges?

Posted by: Isa8686 | March 22, 2010 5:25 PM | Report abuse

This is depressing; it means that, for all the bluster, this wasn't the victory we have long sought. Twenty-two million Americans are still going to be left without healthcare, and it's going to fall to some other congress and perhaps some other President to address that.

Posted by: adamiani | March 22, 2010 5:30 PM | Report abuse


I am sure you must have answered this question somewhere, but after seeing your analysis in this article I am really curious.

If the penalty for being uninsured is only $750 (per year, I presume), why would somebody young want to buy health insurance, which costs a good deal more?

Posted by: avkulkarni | March 22, 2010 5:34 PM | Report abuse

Ezra, are you saying that there is going to be a portion of the population who will remain ineligible for either medicaid or the new subsidies, but for whom buying insurance is also technically too expensive under the new law (above 8% of monthly income)?

So this group won't really receive any direct help from reform, but they also won't be mandated to purchase insurance? Is that correct? If so, about how many people are estimated to fit into this description?

Posted by: ctoma7 | March 22, 2010 6:39 PM | Report abuse

"If the penalty for being uninsured is only $750 (per year, I presume), why would somebody young want to buy health insurance, which costs a good deal more?

Posted by: avkulkarni |

avkulkarni, why would only the young not buy health insurance? Why would anybody buy health insurance? Remember, insurers are required to cover you, sick or healthy. 40% of new enrollees in Massachusetts health care stay covered for 5 months or less. They pay the penalty, get coverage when they get sick, get care, then drop coverage once they finish treatment. I can't imagine why anybody with half a brain would buy insurance unless they are so heavily subsidized that their premiums cost them less than $750 per year.

Posted by: bgmma50 | March 22, 2010 6:56 PM | Report abuse

Among the non-group/other category, why won't they all be eligible for the exchange?

Posted by: rich_in_nj | March 22, 2010 7:15 PM | Report abuse

BobN1: the Individual market is the present individual insurance market ... go to an insurance company, give them info, get a rate. The exchange is open to those who qualify: including those with little or no insurance at work, those who cannot afford the insurance available to them in the individual market, and employees of small businesses.

voxcivitatis: the threshold to qualify for Medicaid is highER than it was, but, for example, working poor at twice the poverty line would not qualify. Since the subsidy kicks out so rapidly, there are likely to be people somewhere between the Medicaid threshold and median income for whom the cheapest insurance in the exchange will be more than 8% of their income.

bennettcurtis: No, the graphs show the Employer Provided pool shrinking slightly, which from the CBO modeling I've read on the Senate Bill is primarily due to some people on particulary crappy Employer provided care being eligible to get better coverage and, after the subsidies, at lower cost to themselves, through the exchanges. A drop from 162m to 159m is not a big drop ... but it IS a decrease.

adamiani: to paraphrase Churchill, at the end of the Battle of Britain in 1940, over two years before the tide of WWII in Europe turned and almost five years until the end of the war ... this is not the end; this is not the beginning of the end; but it may be the end of the beginning. IOW, the fight just won was over the structure within which we must now push for actual health care reform.

Posted by: BruceMcF | March 22, 2010 7:48 PM | Report abuse

Oh, the horrors of immigrants free riding on the socialist gravy train.

Posted by: sparkplug1 | March 22, 2010 7:57 PM | Report abuse

First of all, is the funniest web address I've seen in a long time. Thanks servant119b! It's great to learn that Jesus was conquering souls for CommunIslam when he used godless healthcare to heal the ten lepers.

Second, Ezra, if someone's income is such that available insurance plans cost 8% or more of their monthly income, wouldn't the subsidies cover all or nearly all the cost? Or else wouldn't they qualify for Medicaid? It seems pretty strange that there is a donut hole in coverage here big enough to encompass what sounds roughly to sound like several million people. Are these people who are eligible for a full subsidy but are predicted to fail to take advantage of it?

Posted by: JonathanTE | March 22, 2010 8:15 PM | Report abuse

I am excited about this victory. We have health insurance, but my husband works as an independent contractor. He also has Type I diabetes, and our family coverage is extremely expensive. My mother has been living on a Veteran’s pension and subsequently Social Security for years without health insurance. The health care system in this country has been broken for years. It took President Obama great courage and perseverence to make this issue a priority. Without our health, without proper preventative screenings, what can the citizens of this country hope to achieve? We must be a healthy nation before we can be a successful nation. People cannot get back to work if they are not well. Most U.S. citizens are far from healthy. The stress of paying exorbitant fees for health care, the concern over whether or not we will be seen in a hospital if we cannot produce our insurance cards and fill out the paperwork on a moment’s notice–this is a crisis. Bravo! This is long overdue.

Posted by: CorrieMG | March 23, 2010 12:30 AM | Report abuse

Why do people object to compulsory insurance? If you have a serious accident and do not have insurance, anything could happen.

Posted by: CorrieMG | March 23, 2010 12:35 AM | Report abuse

16,500 new IRS agents at a cost of $10 billion to be hired to enforce Obamacare's health insurance mandates on individuals and businesses. That's on top of the 100's of thousands of new burecrats to be hired to staff the hundreds of new federal government agencies created by Obamacare. With the federal work force now at almost 2.5 million people and growing I guess when Obama said he was going to get people back to work he meant work for the government. Anybody ever stop and think about where the money is going to come from to pay all these government workers when actual unemployment levels are approaching 18%? Who's going to pay the taxes to pay all these government employees?

Posted by: RobT1 | March 23, 2010 11:33 AM | Report abuse

How do you get 10 billion? 100,000 x 16500 ~ 1 billion. the real winners with be in health administration, part of the fastest growing industry anyway. So all you middle manager/ real estate/ business people will have career options again instead of lining up at career fairs. Preventive care instead of emergency care. Sounds like cost savings to me.

Posted by: anti1 | March 23, 2010 3:42 PM | Report abuse

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