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A Project of The Annenberg Public Policy Center

Trump on the ACA and the Uninsured

In an interview with ABC News, President Donald Trump wrongly claimed that “nobody ever deducts all the people that have already lost their health insurance” from estimates on how many have gained insurance under the Affordable Care Act, or stand to lose it if the law is repealed. In fact, estimates from governmental organizations are net estimates.

Trump was asked about the estimate that 18 million Americans could lose insurance if the ACA is repealed entirely, with no replacement. ABC’s David Muir asked, “Can you assure those Americans watching this right now that they will not lose their health insurance or end up with anything less?”

The president responded by disputing the number.

Trump, Jan. 25: So nobody ever deducts all the people that have already lost their health insurance that liked it. You had millions of people that liked their health insurance and their healthcare and their doctor and where they went. You had millions of people that now aren’t insured anymore.

Let’s go through the numbers.

The Centers for Disease Control and Prevention publishes data on health insurance status from the National Health Interview Survey, conducted by the Census Bureau with a sample size of approximately 35,000 households.

The latest report shows that an estimated 28.4 million Americans of all ages were uninsured for January through June 2016. The number of the uninsured in 2010, the year the ACA was enacted, was 48.6 million. That’s a decrease of 20 million people.

We could start the clock a little later, in 2012, the year before the first open enrollment period for the ACA marketplaces — and the year before some Americans received cancellation notices when their individual market plans no longer met the ACA’s benefit requirements. From 2012 through the first half of 2016, the number of the uninsured declined by 17.1 million.

In percentage terms, 8.9 percent of all U.S. residents lacked insurance during the first half of 2016, the lowest uninsured rate on record. (See page 9 of this NHIS report for historical data dating back to 1972.) The rate was 16 percent in 2010, and it has been declining every year since.

There’s no need to modify these numbers for “millions of people that now aren’t insured anymore,” as Trump said. These are the total numbers for the uninsured in the country.

The claim that “millions” lost their insurance or their doctor is a longstanding GOP talking point based on the fact that many with individual market plans received cancellation notices in 2013, when their plans no longer met minimum benefit standards required under the ACA. But that talking point is misleading — those specific plans were discontinued; policyholders weren’t denied coverage. It’s unclear how many had their plans, which they may well have “liked,” discontinued. An Urban Institute study and survey from December 2013 put the number getting cancellation notices at 2.6 million.

To be clear, some who buy their own insurance on the individual market got a better deal before the ACA — the relatively young and healthy who also earn too much to qualify for subsidies under the health care law. And there’s evidence that some have lost or dropped their health insurance coverage even as many more have gained coverage in recent years. But, again, the numbers presented by researchers on insurance gains under the ACA are net. That is, the numbers account for those who, as Trump said, “aren’t insured anymore.”

A RAND Corporation study from 2015 suggested that most of those who had their plans cancelled found coverage elsewhere and remained insured.

That study surveyed the same 1,589 people to measure changes in sources of insurance from September 2013, a month before the first open enrollment period for the ACA’s marketplaces, and February 2015. RAND found that over that time period, covering the first two open enrollment periods, an estimated “22.8 million Americans became newly insured and 5.9 million lost coverage, for a net of 16.9 million newly insured Americans.”

The study, published in the journal Health Affairs, said that “[t]ransitions in health insurance coverage are common in the United States and occur for a variety of reasons, including job changes and family transitions. Recent estimates suggest that the share of people losing coverage between 2013 and 2014 was no higher than the share of people who lost coverage in prior years.”

The authors, who noted that the limitations of their study included a small sample and low response rate, addressed the concern that “people may have lost individual market coverage as a result of plan cancellations.” They wrote: “We found that the vast majority of those with individual market insurance in 2013 remained insured in 2015, which suggests that even among those who had their individual market policies canceled, most found coverage through an alternative source.”

RAND has not published any updated numbers since.

As for the estimate on how many people could lose health insurance if the ACA were repealed — the 18 million number Muir mentioned — that comes from the nonpartisan Congressional Budget Office, which said in a Jan. 17 report that the number of the uninsured would increase by that much in the first year following implementation of a repeal bill put forth by House Republicans in 2015.

That bill would eliminate tax elements of the ACA — including the tax subsidies available for lower-income Americans, penalties imposed on individuals for not having insurance and certain employers for not offering it, and the funding for Medicaid expansion. Insurance market provisions — such as the requirement that insurers accept anyone for coverage regardless of preexisting conditions and not charge more based on health status — would remain.

Most of that 18 million increase in the uninsured, CBO said, would come from repealing the individual mandate penalties. The estimated rise in the uninsured would be much greater once tax subsidies and Medicaid expansion funding were eliminated. In the year following those moves, CBO said, the number of people without health insurance would increase by an estimated 27 million, compared with the expected number of uninsured under current law.

If the insurance market provisions — in addition to the ACA’s funding mechanisms — were also eliminated, the increase in the uninsured would be an estimated 21 million the year following the repeal of tax subsidies and Medicaid expansion, CBO said.