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Aaron E. Carroll Headshot

What a Difference a Year Makes

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Every year about this time, the census releases its yearly numbers on the uninsured. Every year, I write an op-ed or a blog post. Every year, I get a little more depressed.

It's hard to find good news in these numbers. It's even harder because there's just nothing that the Patient Protection and Affordable Care Act is going to do about them this year. Or next year. Or even the next few years. And, over that time, things are going to get worse for a large number of people.

Before we even get started, let's kill a myth. When the census reports uninsured people, they mean people who were uninsured for the entire year. Not part of the year, not on the day they were surveyed -- the whole year. How do I know? Because the people who asked the question say so. The US Department of Health and Human Services, in a 2005 document entitled Understanding Estimates of the Uninsured: Putting the Differences in Context, explains that the Current Population Survey (CPS) tells us about people who were uninsured for the whole year (see Table 1). In fact, it specifically says that the CPS does not give a point in time calculation ("N/A"). It does not matter what other people "say" about it. The CPS reports uninsurance for the whole year. In this year's report it also says:

"They were considered 'uninsured' if, for the entire year, they were not covered by any type of health insurance."

Remember that when you read the rest of this. The number of people who were uninsured for at least part of the year is much higher than those who were uninsured all year. They are at risk. They often can't get care. And we're not measuring them at all. Nor do we take into account that so many people in the United States are under-insured. Just having insurance doesn't necessarily mean you're adequately covered. It doesn't necessarily mean that you won't go bankrupt because of illness. It doesn't necessarily mean that you are protected. But we don't measure under-insurance. We just don't know.

Now that that's out of the way, let's hit hit the low notes on this year's report:

The percentage of people without health insurance increased to 16.7 percent in 2009 from 15.4 percent in 2008. The number of uninsured people increased to 50.7 million in 2009 from 46.3 million in 2008.

That means that there are now more people uninsured in the United States than at any time since the passage of Medicare. Full stop. A total of 4,300,000 more people were without insurance in 2009. Remember as well, all of the 16.7% of Americans who are uninsured are less than 65 years old, because all of those older people get Medicare.

The number of people with health insurance decreased to 253.6 million in 2009 from 255.1 million in 2008.

While the percentage of people who are uninsured has gone up and down, this is the first time that the sum total of people who have insurance has gone down in 23 years. It's also been 23 years since we've been looking.

The number of people covered by private health insurance decreased to 194.5 million in 2009 from 201.0 million in 2008. The number of people covered by government health insurance increased to 93.2 million in 2009 from 87.4 million in 2008.

Think about that for a second. We just passed a huge health care reform bill that, for the most part, is built on the private insurance market. And yet that market is failing us miserably. The number of people covered by government insurance increased by almost 7 million, and the number of people covered by private insurance dropped by 6.5 million. Six-and-a-half million. We're going to build on that? Moreover, the PPACA is going to increase the number of people on Medicaid by a substantial number. That's not until 2014. At this rate, funding Medicaid at the state (or even federal) level is going to need a large infusion of cash.

The percentage of people covered by government health insurance programs increased to 30.6 percent in 2009, from 29.0 percent in 2008.

Again, that's the highest percentage of people on government insurance in 23 years, since we started collecting the data.

The percentage and number of people covered by Medicaid increased to 15.7 percent or 47.8 million in 2009, from 14.1 percent or 42.6 million in 2008.

Go check out the CBO report on the final PPACA bill. They estimated that in 2010, 40 million people would be covered by Medicaid and CHIP. Forty million. That's 7.8 million less than it turns out were on Medicaid last year. How's 2010 going from your standpoint? Is there anyone who thinks things have improved so much that that the number of people on Medicaid is going down? I think it's possible that we'll see 50 million people on Medicaid in 2010, which is 10 million more than the CBO thought would be on Medicaid and CHIP. And things may get worse after that.

The PPACA depends on private insurance covering a certain number of people. This will have repercussions on how much reform will cost and how much government will be involved. I can't imagine anyone will be pleased with the changes in its outlook.

If you thought health care reform was done, prepare to be disappointed. It's barely begun.

Aaron regularly blogs about (mostly) health policy at The Incidental Economist.