They've Got You Covered?

Back in the fall, Clinton took to citing a statistic that Obama's plan would leave out 15 million of the uninsured, a number that Obama has questioned. In a Feb. 2 debate on CNN, Obama said: "I dispute that there are 15 million people out there who don't want [insurance]. I believe that there are people who can't afford it, and if we provide them enough subsidies, they will purchase it."

Frankly, we also found the number to be "dubious" last November when Clinton used it in a debate. Her campaign said at the time she based her claim on a column by The New Republic's Jonathan Cohn.

However, Gruber says the 15 million figure is reasonable and perhaps even too low. He told us that he estimates roughly that Obama's plan would cover about two-thirds of the currently uninsured, which would imply that just over 15 million people would not gain coverage. Gruber's published study didn't specifically address either the Clinton or Obama plans. Rather, it examined a Clinton-like plan that included subsidies and an individual mandate – which he found would cover 45 million of the uninsured – and a plan with just the subsides but not Obama's mandate for children. Gruber found that type of proposal would cover 23 million of the uninsured. There are an estimated 47 million nonelderly Americans without health insurance.

In the study, published by the National Bureau of Economic Research, Gruber says that "if penalties are strong … the mandate is likely to be close to universal." Clinton has not stated what the enforcement mechanism would be under her plan, and she has been evasive when responding to questions on this point. However, she recently said, after much prodding, that garnishing wages was a possibility, along with automatic enrollments or some measure through the tax system.

Sheils at The Lewin Group says evaluations his organization has done, including one recently in Colorado and a national analysis for The Commonwealth Fund, have yielded similar results. He says a plan with subsidies and an individual mandate could cover 90 percent-plus of the currently uninsured, while one without the mandate could reach about 40 percent. Sheils bumps that estimate up to about 45 percent for Obama's plan when considering the candidate's mandate for covering children. (Nine million of the uninsured are kids, and a requirement that they be covered could lead to some adults picking up coverage, too.)

Both of these experts give similar reasons for why a plan without a mandate would not lead to universal coverage. Affordability is not the only barrier to health care. Even when very generous subsidies are offered, people don't always take advantage of them. Sheils and Gruber immediately point to the number of people eligible, but not signed up, for Medicaid or the State Children's Health Insurance Program, which are free in almost all cases. Sheils estimates about 25 percent to 30 percent of those eligible for such government programs don't enroll. More concrete numbers are available for children: Among the 9 million uninsured children, 74 percent are eligible for Medicaid or SCHIP, according to the Kaiser Family Foundation. Kaiser cites a lack of awareness and difficulty applying for these programs as reasons parents don't enroll their kids.