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A Project of The Annenberg Public Policy Center

Thirty Million Uninsured

One of the items we noted in our Sept. 10 wrap-up of President Barack Obama’s televised prime-time address to Congress was his carefully worded estimate of the number of uninsured citizens.

Obama, Sept. 9: There are now more than 30 million American citizens who cannot get coverage.

We said that Obama appeared to be underestimating the number of uninsured, even if we subtract the estimated 10 million uninsured who are not U.S. citizens. With the Census Bureau now reporting 46.3 million people without insurance, one might think that the correct figure should be closer to 36.3 million citizens without insurance.

A Sept. 10 blog post by Peter Orszag, the director of Obama’s Office of Management and Budget, explains the president’s reasoning for using the lower number:

Orszag: The Census report indicates that of the 46 million uninsured individuals, 34 million were native born and 2.8 million were naturalized citizens. The report thus shows that there were 36.8 million uninsured U.S. citizens (native born and naturalized) in 2008. An alternative calculation includes legal immigrants, which based on a figure from the Pew Hispanic Center would bring the total to something like 39 million.

Some ambiguity surrounds how to treat individuals who are already eligible for public insurance programs like Medicaid and S-CHIP but do not enroll in those programs, which estimates from the Kaiser Commission on Medicaid and the Uninsured suggest may amount to millions of individuals. These individuals are uninsured but some interpretations would suggest they should not be counted among those who "cannot get" coverage. Subtracting them from the total would produce a number closer to 30 million.

The numbers do work, as long as you include uninsured non-citizens who are in the country legally to arrive at the final number. Of course "legal immigrants" are not "citizens," which is the word Obama used in his speech. But Obama has made no secret of his support for providing health care benefits for legal non-citizens.

Here’s how the numbers break down: The Kaiser Commission estimates that 25 percent of the uninsured are eligible for either Medicaid or the Children’s Health Insurance Program (formerly SCHIP). That works out to about 11.6 million people, leaving just 34.7 million people who neither have insurance nor are qualified for public insurance. When we subtract the 5.6 million estimated illegal immigrants who lack health care, we’re left with about 29.1 million.

That’s a little short of 30 million. But it’s hard to be perfectly precise here – especially since the math already combines estimates from three different studies, each of which draws on data from a different year.

And there are a number of additional complications to consider. For instance, as we wrote in our June 24 article, "The ‘Real’ Uninsured," some states periodically place caps on CHIP enrollment. So some people who qualify for the program could be turned away if caps have already been reached. Moreover, the Kaiser Commission study in question uses data from 2004. In January 2009, Congress expanded the CHIP program, which extended coverage to at least 250,000 more children in its first five months. It’s too soon to know for sure whether that has raised or lowered the percentage of eligible but uncovered children.

Some of our readers have also pointed out that the president’s use of the word "cannot" presents still another difficulty: There are some people in the ranks of the uninsured who could purchase insurance but who choose not to do so. That’s true, but as we’ve said before, it’s impossible to assign precise numbers to this group, so it is unreasonable to expect OMB’s back-of-the-envelope calculation to exclude an unknowable number.