The Right Prescription

The Myth of the 46 Million

The truth behind everybody's favorite health care statistic.

By 3.20.09

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"Even for folks who are weathering this economic storm, and have health care right now," President Obama said at this month's White House health care summit, "all it takes is one stroke of bad luck -- an accident or an illness, a divorce, a lost job -- to become one of the nearly 46 million uninsured…"

Whether it's in political speeches, commentary, newspaper features, or hard news stories, the statistic of 46 million uninsured is one of the most-widely cited numbers in the health care debate. It promotes the idea that nearly one out of every six Americans does not have access to health care and it plays into the arguments of those calling for massive expansion of government to fix the problem. Yet the ubiquitous figure is highly misleading.

To be clear, the statistic is not pulled out of thin air. It comes from an annual report by the Census Bureau, which most recently pegged the number of uninsured at 45.7 million for 2007. But the problem lies in the way the statistic is commonly cited and understood.

For starters, the statistic does not mean that there are "46 million uninsured Americans," as the New York Times reported in a recent story on health care, and as is echoed throughout the media. Just a quick look inside the Census Bureau data shows that 9.7 million of the uninsured are not citizens of the United States. Liberals can argue that we still have a moral duty to cover non-citizens, but this doesn't change the fact that as a matter of accuracy, the Census data only tells us that 36 million Americans are uninsured.

But this doesn't fully convey the problematic nature of the 46-million statistic. As even the authors of the Census Bureau report themselves acknowledge, "health insurance coverage is likely to be underreported" in the Current Population Survey from which the health insurance data is derived. The reason is that respondents are asked in February through April about their health coverage status in the previous calendar year. Some may answer the question as intended, but others may cite their current insurance status, and others may say they were without insurance even if they only spent a portion of the year without coverage.

"[T]he estimate of the number of people without health insurance," according to the report, "more closely approximates the number of people who are uninsured at a specific point in time during the year than the number of people uninsured for the entire year."

In reality, a person who goes without coverage for a few months while between jobs is in a completely different boat from somebody who is permanently without insurance. But the broad citation of the headline figure would have you believe that there are literally 46 million people who never, ever, have coverage.

How many people actually spend the whole year without health insurance? It's difficult to say, and recent data is hard to come by. But in 2003, the Congressional Budget Office took a stab at answering the question, and looked at two studies from 1998 that conducted interviews multiple times over the course of the survey period. One study pegged the number of people who were uninsured for the entire year at 31 million, while another put it even lower, at 21 million. In either case, the number was significantly lower than it was in 1998's Current Population Survey, which found 43.9 million uninsured.

Another problem with citing the 46-million figure is that many of those who are identified as uninsured are actually eligible for existing government programs but simply never bothered to enroll. In 2003, a BlueCross BlueShield Association study estimated that about 14 million of the uninsured were eligible for Medicaid and SCHIP. These people would be signed up for government insurance if they ever made it to the emergency room.

In addition, some of the 46 million could theoretically afford health coverage, but chose not to purchase any. In 2007, 17.6 million of the uninsured had annual incomes of more than $50,000 and 9.1 million earned more than $75,000. In fact, as Sally Pipes notes in the Top Ten Myths of American Health Care: A Citizen's Guide, those making more than $75,000 per year are part of the fastest growing segment of the uninsured population.

The Census figures also show that 18.3 million of the uninsured were under 34. Some in this age group may have simply determined that they are young and healthy and thus can do without coverage.

When all of these factors are put together, the 2003 BlueCross BlueShield study determined that 8.2 million Americans are actually without coverage for the long haul, because they are too poor to purchase health care but earn too much to qualify for government assistance. Even being without insurance still doesn't mean they won't have access to care, because federal law forbids hospitals from denying treatment to patients who show up at the emergency rooms.

This exercise isn't about downplaying the problems facing the American health care system, but a necessary part of devising the proper remedies. Under current state laws, mandates force insurers to provide certain benefits, meaning that young and healthy Americans must choose between paying exorbitant premiums to cover treatments that they don't need or going without health insurance. Many of these so-called "young invincibles" who are included in the ranks of the uninsured could be wooed into the market were they allowed to purchase catastrophic insurance with lower monthly premiums.

Right now, the tax code exempts people from paying taxes on health care benefits purchased through their employer, while denying the same tax advantages to individuals. Ending this discrimination would make health care more affordable to those who are self-employed or not covered through their workplace. In addition, this would allow Americans to have health care policies that are portable, so it would reduce the gaps in coverage people can face when they quit or lose a job.

Those pushing for a major government intervention in health care are distorting the 46-million statistic to boost their cause, and by disseminating it so widely without further elaboration, the media is rigging the game in their favor. 

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About the Author

Philip Klein is The American Spectator's Washington correspondent. You can follow him on Twitter at: http://twitter.com/Philipaklein