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Tallying the Uninsured a Challenge in Health Care Reform Debate

With apologies to the poet:

“How Do I Know Thee Are Uninsured?
Let Me Count the Ways.”

A recent admission by the Census Bureau that it has miscalculated the number of uninsured in the U.S. for the last few years sheds light on just how complex and political it is to measure how many residents lack health insurance.

According to the agency, a computer programming error is behind the overestimate, and the actual number of uninsured is 44.8 million, not 46.6 million as first announced.

How do estimates of the uninsured affect how policymakers look at the issue?

While the new figures from the Census Bureau should not have an impact on the overall national policy debate, they might, according to John Holohan — director of the health policy center at the Urban Institute, a policy think tank in Washington, D.C. “The numbers suggest things are not quite as bad as everybody has been saying,” he said, adding, “I can see this might create some doubt about what we know and provide more ammunition for those who don’t want to take any policy steps.”

California More Confident

Although some estimates of the uninsured nationwide are shifting, the same is not true in California, where policymakers seem more confident than their national counterparts that estimates for the state are correct.

California is working with data from the UCLA Center for Health Policy Research, which is partially funded by the state. The center gathers information through the California Health Interview Survey.

“There was never an issue. We were always going to use CHIS,” said Richard Figueroa, a health care policy adviser to Gov. Arnold Schwarzenegger (R). The UCLA center has a thorough and sophisticated measurement and interview system and a sample of interviews large enough to produce county-level data, Figueroa noted.

The governor’s office is using the most recent CHIS data, which shows that 6.5 million Californians were uninsured at some point in 2005. This might be a coverage lapse of a few days as someone moves into a new job with coverage, or a yearlong gap because the person works at a job without health care benefits. Using a snapshot of coverage, there are 4.8 million people without insurance at any point in time in California.

That’s the figure — 4.8 million — that the governor’s planners are using as they try to design a new health insurance system for the state.

Significantly, other state legislators pitching health care reform are using the same figures. Senate President Pro Tem Don Perata (D-Oakland), Assembly Speaker Fabian Núñez (D-Los Angeles) and Sen. Sheila Kuehl (D-Los Angeles) all have different approaches to overhaul the health care system than the governor, but for planning purposes, they all use the same figures — those generated by the UCLA center.

Coverage Varies Widely

CHIS data shows that regardless of which plan is being discussed, the impact would be felt differently around California because the state has various diverse pockets of uninsured people.

In the San Francisco Bay area, almost two-thirds of residents have year-round health coverage through their jobs, according to the UCLA survey. By comparison, the figure is much lower — 46% — in the San Joaquin Valley and Los Angeles County, where 49% of residents have year-round, employer-sponsored health insurance. In those areas, Medi-Cal, the state’s health program for the poor, and other public health insurance programs are much more significant as a source of coverage than in the more affluent Bay Area counties.

These figures help to illustrate that “the uninsured population is not one unchanging group of individuals, but rather a constantly changing group, mirroring the changing nature of employment and income in the economy,” as stated in a recent HHS report.

The federal report indicated that about half the people lacking coverage had been uninsured for at least a year and that about 20% had been without coverage for three months or less.

Policymakers might offer very different approaches when thinking about coverage for people in brief transitions from one insurance plan to another as they switch jobs than they would advocate for people who go the whole year without insurance and could face financial catastrophe if they happen to suffer an accident or a major illness.

And then there is the challenge of covering those who don’t even want to think about buying insurance. About 20% of uninsured Californians are 18 to 24 years old, according to an analysis by the Pacific Research Institute.

“With few assets to protect, a sense of invincibility, little experience using the health care system and no anticipation of immediate need, the private purchase of health insurance does not seem like a good deal,” the analysis stated. “And he or she might be right. Americans in this group spend out of pocket $546 a year on health services. By contrast, they spend $1,636 dining out and another $950 on entertainment. A high-deductible health plan would cost $408.”

Some Obstacles Linger

Whether you consider data from the multiple federal surveys or from UCLA, the result is the same: a lack of health insurance for a significant number of U.S. residents.

“The fact is that we’ve got about 15% of people in the United States who are uninsured,” Paul Fronstin, health policy analyst with the Employee Benefit Research Institute, said.

Interest in the uninsured as an issue ebbs and flows. It surged during the 1992 presidential campaign, which led to former President Clinton’s ultimately unsuccessful efforts in 1993 and 1994 to deal with the issue. Now interest is surging again, with California and other states leading the way this time in the policy debates.

According to Fronstin, precise numbers about the ranks of the uninsured don’t matter as much as the fact that “we haven’t reached agreement yet on how to address the problem.”

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