The early figures on the Affordable Care Act are raising some concerns for those who believed that it would address the problem of the uninsured. Christopher Weaver and Anna Wilde Matthews (Wall Street Journal) report:
Early signals suggest the majority of the 2.2 million people who sought to enroll in private insurance through new marketplaces through Dec. 28 were previously covered elsewhere, raising questions about how swiftly this part of the health overhaul will be able to make a significant dent in the number of uninsured.
A McKinsey & Co survey cited in the piece suggests that only 11 percent of those who purchased coverage under the Affordable Care Act between November and January were previously uninsured. The numbers are somewhat better from other sources, but in each case a majority of those who purchased insurance were previously insured.
Granted, the first few months of the Affordable Care Act were particularly chaotic, and many of those who managed to navigate their way through the website suffered sticker shock (McKinsey found that affordability was cited by 52 percent of those who shopped for a plan but decided not to purchase one). But the numbers seem peculiar nonetheless.
Megan McArdle (Bloomberg) tries to make sense of the numbers and arrives at two possibilities: while it may be the case that the uninsured may be waiting for the March deadline,
[t]he second possibility is more troubling: There may be something seriously wrong with our understanding of who the uninsured are, and what they are willing and able to buy in the way of insurance. I don’t know exactly what the fault may be in our understanding. But if the numbers stay this low, I’d say we need to reassess the state of our knowledge about the uninsured — and the vast program we created to cover them.
All of this leads me to wonder whether part of the problem is the category itself. One prominent policy text cautions: “The astute policy analyst would do well to remember that every number is an assertion about similarities and differences. No number is innocent, for it is impossible to count without making judgments and categorization.” Individual members of a class—the uninsured—may share a common feature (a lack of insurance). But a key question involves causality: why do they lack insurance? If you get the causal story wrong, the policy response will not have the intended impact. Those who are relatively affluent but lack insurance likely have little in common with those who qualify for Medicaid but fail to participate (other than the fact that they are uninsured). I am skeptical that their insurance status constitutes a policy problem comparable to those who are involuntarily uninsured for extended periods of time.
I am not sure what the final numbers will look like, but it would be rather ironic if the largest expansion of the welfare state in the past forty years had its greatest impact on those who were already insured, not those who were uninsured.