Reading Comprehension

The argument in "Obama Math" follows from the following false premises: the uninsured are comprised of the following roughly equal groups,

1. Illegal immigrants
2. People eligible for public insurance, but not reached by them
3. People who have access to prive insurance but decide it is too expensive
   

These premises are contradicted by the very study cited, so the argument that rests on them can be dismissed.

In fact, it is not possible for these premises to be more thoroughly opposite what the Kaiser study actually says. Anyone with basic, grade-school level reading comprehension skills can discover this by reading the study, "The Uninsured: A Primer: Key facts about Americans without health insurance", Kaiser Family Foundation, 2008 (pdf). Or you can read the Senate Testimony from the Kaiser Foundation in 2009. Or read the U.S. National Academy of Sciences, Institute of Medicine 2009 report "America's Uninsured Crisis". I have cited all these studies before.

But let me address the above false premises in turn.

1. Illegal immigrants

There is brief mention of citizenship in the Kaiser study:

"The large majority of the uninsured (79%) are native or naturalized U.S. citizens."

The remaining 21% are explicitly identified as non-citizens. There is no mention of illegal immigrants. So much for premise (1).

2. Eligible, but not reached by public programs

There is zero mention in the study of people who are enrolled in public programs, but who nevertheless are not "reached", that is, do not receive due coverage. So the only viable interpretation of premise (2) is that one-third of the uninsured are eligible for public insurance, but not enrolled.

(By the way, reaching all those enrolled is quite an accomplishment for a supposedly inefficient government program. I wonder how many people are enrolled in private insurance who do not receive or are denied due coverage?)

There is one single mention of the enrollment issue in the 31-page Kaiser study:

"Medicaid and SCHIP cover half of all low-income children. These programs have played a critical role in improving access to care for children. Still, two-thirds of uninsured children are eligible for Medicaid or SCHIP but are not enrolled.43 Some families are not aware of the availability of the programs or may not believe their children are eligible. But, many families face barriers to enrolling and keeping their children in public programs, including rules that require U.S. citizens to document their citizenship and identity when applying for Medicaid or renewing their coverage."

But only 20% of the uninsured are children to begin with, so we are talking about less than 14% of people being uninsured due to failure to enroll in public insurance. So much for premise (2).

If we care to take a brief stroll through the real world, the real study explicitly repeats, for 31 pages, the problem of ineligibility:

"Medicaid covers some parents and low-income individuals with disabilities, but most adults without dependent children—regardless of how poor—are ineligible for Medicaid. As a result, over 40% of poor parents and adults without children are uninsured (Figure 19)."

"Adults make up more than their share of the uninsured because they are less likely than children to be eligible for Medicaid"

"Public coverage had also increased among adults between 2000 and 2004, but with Medicaid’s limits on adult eligibility, it was not enough to buffer the loss of job-based coverage. "

"The near-poor (those with incomes between 100% and 199% of the poverty level) also run a high risk of being uninsured (29%), in part, because they are less likely to be eligible for Medicaid. "

"When people are unable to obtain employer-sponsored coverage and are ineligible for Medicaid, they may be left uninsured for long periods of time if individual coverage is either unaffordable or unavailable due to their health status."

"For example, a parent in a family of three working full-time at the minimum wage could not qualify for Medicaid in 29 states in 2007.44"

Ineligible. Not "eligible, but not being reached". Ineligible.

It's striking that this group of people, constantly referred to in these studies, is absent from premises (1) (2) and (3).

Of course, we could expand public programs to make more poor people eligible, a strategy which has insured millions of adults and children in the past, according to the study. We could even eliminate the minor enrollment problem by making public insurance available to everyone. Few people scratch their heads trying to figure out if they are poor enough to "qualify" for public libraries, museums, parks, or schools. I think that's because these are free, public services, there are no complicated rules designed to exclude most people and protect private sector profits.

But that would mean more of the bad kind of spending, and less of the good kind of spending, like the premiums we all pay and the taxes we all pay to subsidize private insurance profits right now, which the Kaiser study also discusses. Anyway, on to premise (3).

3. One third of the uninsured have access to private insurance, but decide it's too expensive

I'll just quote the study. See the actual study for nifty pie graphs. Keywords: afford, unaffordable, poor:

"Despite strong ties to the workforce—over eight in ten uninsured come from working families—about two-thirds of the uninsured are individuals and families who are poor (incomes less than the federal poverty level or $21,203 for a family of four in 2007) or near-poor (with incomes between one and two times the poverty level). "

"For many of the uninsured, the costs of health insurance and medical care are weighed against equally essential needs. The uninsured are about three times as likely as those with health coverage to live in a household that is having difficulty paying monthly expenses as basic as rent, food, and utilities.20"

"In 2007, 58% of all low-income employees were offered and eligible for employer-sponsored coverage, leaving more than four in ten without access to this coverage (Figure 16)."

"Despite having lower incomes and thus typically fewer resources to pay for necessities, 62% of low-income employees who are eligible for employer-sponsored coverage choose to enroll."

And just for fun, a quote from the Institute of Medicine 2009 report (cited above):

"Overall, fewer workers, particularly those with lower wages, are offered employer-sponsored insurance, and fewer among the workers that are offered such insurance can afford the premiums. ... For many individuals and families without employer-sponsored group coverage, nongroup coverage is unaffordable."

Unaffordable. Not "they had access, but decided not to get private insurance". Unaffordable.
So much for premise (3).