No, 20 Million Haven’t “Gained Coverage” Under Obamacare

A report in
the New England Journal of Medicine tallies up the various ways
that Obamacare has expanded health insurance coverage and estimates
that a total of 20 million people have “gained coverage under the
ACA” as of May 1. It’s a count of people obtaining coverage,
whether or not they had it before, not people who were previously
uninsured, and it’s meant to suggest the sweep of Obamacare’s
impact following its first enrollment period. But the sources used
for this tally don’t offer the kind of precision necessary to be
confident in the headline estimate. It’s not possible to pin down
the exact number of people covered because of the law, but this
figure is almost certainly overstated.

Here’s the graph showing where the figures come from.

Let’s start with the 1 million young adults. That number is
related to Obamacare’s requirement that insurers carry adult
dependents up to age 26, and it’s lower than the 3 million the
administration has long claimed from that provision, based cherry
picked year-to-year comparisons. The 1 million figure is within the
realm of plausibility, but it still might be high. As Avik Roy of
the Manhattan Institute has noted,
the only way you get to roughly one million here is if you credit
Obamacare’s requirement for essentially the entire recent expansion
of coverage amongst young adults. So, sure, a million is
possible—but it’s also possible that the number is quite a bit
smaller.

The next figure, which adds 8 million marketplace sign-ups into
the mix, comes from the administration’s reporting on how many
people have signed up for private coverage through the law’s health
exchanges. But as the authors note in the article, that figure
doesn’t account for people who signed up and didn’t pay, which,
based on government and insurance industry estimates, will likely
cut 10 to 15 percent from the total. That would bring the total
closer to 7 million (and that ignores the potential for attrition
due to non-payment in later months).

The article also count 5 million covered via purchase directly
from an insurer—that is, people who bought individual insurance,
but not through the law’s exchanges. As The Washington
Post’s Glenn Kessler
pointed out recently when examining a similar coverage claim
from the administration, these plans are not an obvious choice for
inclusion: 

Off-market plans are sold directly by insurance brokers or
insurance companies, meaning they generally do not qualify for
Obamacare subsidies. (An insurance agent could help someone enroll
on an exchange if they have proper certification.) But off-market
plans do include the protections included in the law, such as
guaranteed coverage for people with preexisting conditions and a
package of essential benefits.

Still, CBO
calculated that the number of off-exchange plans would drop
from about 10 million to 5 million as people moved to buying
insurance on the exchanges. So why should she tout a figure that
was due to go down because of the law, especially because she said
she was talking about people with “affordable coverage”?

Finally, the graph cites 6 million enrollments in Medicaid or
CHIP (the Children’s Health Insurance Program). That number
presumably comes from a June administration
report stating that, nationwide, Medicaid enrollment has
increased by 6 million following Obamacare’s open enrollment
period. But this number, too, likely overstates Obamacare’s direct
effect on the expansion.

For one thing, it includes people who were previously eligible
for Medicaid, and merely signed up after October. For another, as
the authors note, it includes people in states that did not expand
Medicaid under Obamacare (although the administration reports that
sign-ups rose much faster, at a rate of 15.3 percent, in states
that participated in the expansion, compared with 3.3 percent in
non-expansion states). The administration’s report also says that
states are still reporting Medicaid figures in a variety of
different ways, and thus cautions that this “limits the conclusions
that can be drawn from the data.” Even the administration does not
seem to want to claim the entire 6 million: “It is important to
note that multiple factors contribute to the change in enrollment
between April 2014 and the July-September 2013 baseline period,”
the report says, “including but not limited to changes attributable
to the Affordable Care Act.” Obamacare was part of the story—but
not all of it.

It seems clear that millions of people, some of whom were
previously insured and many who were not, did in fact obtain health
coverage through Obamacare’s various coverage-expanding provisions.
But it’s too early to say exactly how many so far—only that 20
million is almost certainly an overstatement.