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A Project of The Annenberg Public Policy Center

Not ‘Everybody’ Is Covered Under ACA

President Obama went too far in saying the Affordable Care Act meant “everybody” would have “basic health care.” The law doesn’t create a universal health care system, and not everyone will have insurance. In fact, tens of millions will still be uninsured.

Obama made the comment in remarks on April 1 in the White House Rose Garden. The president announced that 7.1 million Americans had signed up for insurance on the federal and state marketplaces through March 31, the end of the open enrollment period. Plus, an estimated 3 million young adults, under age 26, were able to join their parents’ plans because of the law, and millions more Americans are now eligible for Medicaid coverage or the Children’s Health Insurance Program. He boasted of the progress that had been made under the law, but went beyond the facts when he said this:

Obama, April 1: Nobody remembers well those who stand in the way of America’s progress or our people. And that’s what the Affordable Care Act represents. As messy as it’s been sometimes, as contentious as it’s been sometimes, it is progress. It is making sure that we are not the only advanced country on Earth that doesn’t make sure everybody has basic health care.

The ACA doesn’t change that status for the United States: The country still is one of just a few advanced nations that don’t “make sure everybody has basic health care,” to borrow Obama’s phrasing.

The nonpartisan Congressional Budget Office estimates that tens of millions will gain insurance, but the ACA was never expected to cover everyone. CBO says there will be 25 million fewer uninsured because of the law, as early as 2016. That leaves 31 million still uninsured.

Some may choose to pay the tax penalty rather than buy insurance. Others may get an exemption from the requirement to have coverage. Those who make too little to file a tax return can be exempt, for instance, and the same is true for those who can’t find affordable coverage — meaning if insurance would cost more than 8 percent of their household income. “Hardship” exemptions could be granted for several reasons, including bankruptcy, being a victim of domestic violence, a death in the family, unpaid medical bills, and having an individual market plan canceled and not finding “affordable” coverage among marketplace plans.

Plus, there’s a hardship exemption for those who could have been eligible for Medicaid if their state had expanded the program under the law. Since 24 states haven’t expanded Medicaid, that leaves millions of below-poverty Americans falling into a gap between their state’s Medicaid eligibility level and being eligible for subsidies, which are available for those earning 100 percent to 400 percent of the federal poverty level. (The Kaiser Family Foundation estimated in December 2013 — when 25 states weren’t moving forward with expansion — that nearly 5 million would fall into this coverage gap and likely remain uninsured.)

Obama, of course, would like all states to expand Medicaid, and he addressed that issue in his Rose Garden remarks, saying: “[M]illions of Americans remain uncovered in part because governors in some states for political reasons have deliberately refused to expand coverage under this law. But we’re going to work on that.”

But even if all states did expand Medicaid, everyone wouldn’t have health insurance. In 2010, the CBO estimated that, because of the law, 94 percent of Americans would be insured. Now, the CBO’s estimate is that 92 percent would be insured. (Both figures exclude those in the country illegally.)

Obama went on to say that the goal was for no American to be without health care, and that “that goal is achievable.” Perhaps, but not with this law alone.

Obama, April 1: But today should remind us that the goal we set for ourselves — that no American should go without the health care that they need; that no family should be bankrupt because somebody in that family gets sick, because no parent should have to be worried about whether they can afford treatment because they’re worried that they don’t want to have to burden their children; the idea that everybody in this country can get decent health care — that goal is achievable. We are on our way.

New legislation would have to be passed to get to universal coverage. Despite expressing support back in 2003 for a “single-payer” health system, in which everyone has health insurance through the government, Obama hasn’t embraced the idea as a presidential candidate or while in office. Advocates for a single-payer system have been critical of the president for excluding them from discussions on overhauling the health care system.

The plan put forth by Obama in 2007 and 2008, when he was first campaigning for president, wouldn’t have covered everyone, either, despite the fact that he claimed it would. At that time, Obama didn’t support an individual mandate to require individuals to have insurance or face some kind of penalty, making his plan less effective at covering most Americans than that of Hillary Clinton, who called for such a mandate. Experts predicted that Clinton’s plan would come close to universal coverage, but even that plan, just like the ACA, wouldn’t cover everyone.

Obama ads in 2008 wrongly touted his plan as “universal coverage for all Americans,” and he said in a 2007 speech in Hartford, Conn., that “I will sign a universal health care bill into law by the end of my first term as president that will cover every American.”

Less than two years into his first term, he did sign a health care bill that’s expected to expand insurance coverage to tens of millions of Americans. But it won’t cover everybody.

— Lori Robertson