Today, the Census
Bureau reports that there are 44.9 million uninsured. But this
Census Bureau number is inadequate and, in several important
How best to help
the uninsured has been a prominent feature of domestic policy for
decades. But before there is a solution to this pressing national
problem, it must be accurately defined. And therein lies the
inadequacy of the Census Bureau data.
In fact, there are
several different estimates of the number of uninsured individuals
in America and their characteristics. Discrepancies between these
various estimates are not simply a matter of who was counted, but
rather how they were counted and when they were
counted. As the Census Bureau releases its numbers on the
uninsured, federal and state policymakers should keep in mind that
how the Census counts the uninsured matters as much or more
than the aggregate number.
Getting it Right
The problem of the
uninsured is complex. For policy makers crafting a solution, the
problem first must be clearly defined. But a solution is impossible
unless policymakers can determine exactly who are the uninsured,
how many are in their ranks, and why they lack insurance. We do
know that, overwhelming, the uninsured are in working families and
work for small businesses.
Today, the job of
counting the uninsured falls on the U.S. Census Bureau. The
Bureau's chosen instrument for this task is a database called the
Current Population Survey (CPS). But as Census officials themselves
admit, the Bureau is ill-equipped to complete this task with
accuracy. In Appendix C of its report on "Income, Poverty, and
Health Insurance Coverage in the United States," the Census Bureau
admits that "Health insurance coverage is likely to be
underreported in the CPS"
and that underreporting "appears to be a larger problem than in
other national surveys that ask about health insurance." The Bureau speculates
that "Some reasons for the disparity may include the fact that
income, not health insurance, is the main focus of the ASEC (Annual
Social and Economic Survey) questionnaire."
officials also acknowledge underreporting of the number of Medicaid
enrollees. They say that the problem arises because their survey
"is largely a labor force survey,
interviewers receive less training on health insurance concepts.
Additionally, many people may not be aware that they or their
children are covered by a health insurance program if they have not
used covered services recently, and therefore, they would fail to
Whether this explanation would close the gap between the Bureau's
numbers and other reports on the uninsured is unclear.
The Medicaid Mystery
It is clear,
though, that policymakers should carefully scrutinize the Census
Bureau's estimates on Medicaid enrollment.
Medicaid is the
joint federal and state program that provides health coverage to
the poor and indigent.
Just as among the
uninsured, there is churning within the Medicaid population. When a
Medicaid recipient leaves the program-whether by receiving coverage
from an employer or by surpassing Medicaid income eligibility
limit-from that point on, he or she is no longer counted as
enrolled in Medicaid in "point in time" surveys taken after that
point. But this former recipient is counted in surveys that look at
Medicaid enrollment "at any point" during that year.
Part of the apparent over-counting of the uninsured in the Census
data is likely due to a serious undercounting of Medicaid
enrollees. While the Centers for Medicare and Medicaid Services
(CMS) reported Medicaid enrollment of 51 million in 2002, the
Census reported only 33 million, a difference of 18 million people.
This trend continues in 2003 with a .7 percentage point increase in
Medicaid enrollment by the Census Bureau, putting that number at 35
million, but CMS reports 53 million enrollees. This discrepancy is,
to say the least, problematic.
At the very
least, the undercounting of Medicaid recipients and the
undercounting of insurance coverage, as admitted and described by
Census officials, demonstrate that the Census Bureau's figures on
the uninsured do not accurately reflect reality and may lead
policymakers and the public to incorrect impressions about the
uninsured. Policymakers and policy experts have no excuse for not
owning up to this fact and should supply it as a major caveat
whenever making use of the Census data on the uninsured.
Bureau's statement that its survey "is
not designed primarily to collect health insurance data" should be accepted at
face value: it is an internal recognition that the Bureau's
methodology for this task is flawed.
should require the Census Bureau to make appropriate methodological
adjustments and thus better calculate the number of the uninsured
and their durations of uninsurance. Congress and the Administration
should take the necessary steps to see that the Census produces
this sort of data in a clear, comprehensive, and reliable
The issue of
uninsurance is simply too important for its public face to come
from an indifferent and inaccurate survey. Only when the Census
Bureau significantly revises its methodology should policy makers
and the public trust this dataset as the basis for public
Derek Hunter is a
Research Assistant in the Center for Health Policy Studies at The