ObamaCare's Missing Uninsured

January 22, 2014

"I'm not going to walk away from 40 million people who have the chance to get health insurance for the first time," President Obama declared in November. Echoing his boss, White House press secretary Jay Carney insisted that millions of Americans are now "able to avail themselves of quality, affordable health insurance . . . many of them for the first time."

The Affordable Care Act would right a great social wrong. Or so we were told. But reality is again intruding on the Obama administration's narrative.

This newspaper reported Saturday that between 65% and 80% of those who have signed up for health insurance through the federal or state ObamaCare exchanges previously had coverage, according to insurers. A survey by McKinsey & Co. suggested that only 11% of those who purchased plans through the exchanges were previously uninsured.

Surprised? We shouldn't be. This was forecast in a February 2011 study underwritten by the Department of Health and Human Services and the Department of Veterans Affairs. Researchers at the VA, Boston University's School of Public Health and Harvard Medical School's Mongan Institute for Health Policy focused on "crowd-out" effects in which employees and their families are moved "from private to public insurance without reducing the number of uninsured very much." The study concluded that, over the long run, theAffordable Care Act "will shift increasing numbers of workers from employer-sponsored insurance to public insurance and federally-subsidized insurance purchased through exchanges."

Crowding-out seems to have started earlier than anticipated. This is probably because the study (a) did not consider ObamaCare's impact in causing the cancellation of many policies in the individual and small-group markets, or (b) its incentives for companies to drop employer-provided coverage, especially businesses with fewer than 50 workers. Whatever the explanation, most people getting private insurance under ObamaCare already had it, probably with lower premiums and deductibles.

There are also questions about Mr. Obama's Twitter claim on Jan. 10 that "6 million Americans have already signed up for coverage thanks to health reform." That figure was calculated by adding the 2.1 million who selected a plan through the federal or state insurance exchanges in October and November with the 3.9 million who signed up for Medicaid during the same period.

But according to a Dec. 20 report from the Centers for Medicare and Medicaid Services, 911,277 of the 1,650,231 people found eligible for Medicaid in November live in states that did not expand Medicaid as allowed under ObamaCare. The total in states that participated in ObamaCare's Medicaid expansion was 738,954.

Why does this matter? Because fully 55% of the people who signed up for Medicaid live in states where they were eligible before the Affordable Care Act. It's also likely that many in the states that expanded Medicaid would also have qualified under the previous, lower threshold in place before ObamaCare.

It's worth noting, too, that compared with the pre-ObamaCare period of July-September 2013, Medicaid applications in November were down 4.2% in states that expanded Medicaid and 15.2% in states that did not. One would expect all the hubbub about the new law, especially the availability of Medicaid in states that expanded coverage, would have produced more, not fewer, applications.

Also, many state totals included people already participating in Medicaid and renewing coverage. Seven of the 25 states and the District of Columbia that expanded Medicaid as permitted by ObamaCare are listed in the CMS report as including renewals in their totals, as are nine of the 25 states that did not elect to expand Medicaid. There may be others.

Did all these patterns continue in December? We don't yet know. Although CMS reported November's numbers on Dec. 20, Jan. 20 came and went without a CMS update for December. Perhaps they had a computer problem.

Regardless, most people signing up for the exchanges or Medicaid were already covered by private plans or eligible for Medicaid. This is not how it was supposed to be. Mr. Obama promised coverage for those without insurance and no disruptions for those already possessing it. Instead, tens of millions of Americans are not receiving coverage while there are massive disruptions for those who had plans before ObamaCare.

In doing great damage to our health-care system, Mr. Obama and congressional Democrats are also discovering there's a big price for massive incompetence, hype and misdirection.

A version of this article appeared January 23, 2014, in the U.S. edition of The Wall Street Journal, with the headline ObamaCare's Missing Uninsured and online at

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