How Many of Obamacare’s New Enrollees Were Uninsured Last Year? Why It Doesn’t Matter

Charles Gaba, the enrollment guru who has been tracking Obamacare sign-ups since October, now estimates that by April 15, some 17 million Americans will have purchased their own insurance policies either in the Obamacare Exchanges (8 million) or off-Exchange (9 million)

But how many of them were uninsured and how many were simply replacing policies that Obamacare had forced insurers to cancel?  This is the question conservatives ask.  After all they argue, if most of these folks already had coverage, we have just wasted a great deal of time and money moving them from a policy they chose to one that President Obama prefers.

There are two answers to their question. The first is that while we don’t have an exact number as to how many of the new enrollees were uninsured, we do know that, thanks to Obamcare,  the percent of Americans who are “going naked” has declined. New Gallup data shows that the uninsured rate fell from 18.1% in the third quarter of 2013 to 15.6% in the first quarter of 2014.

That said, Gaba offers a second, even better, answer: “It doesn’t really matter.” 

I agree. As he explains:

“It doesn’t matter because every one of those new policieswhether on-exchange or off-exchange; whether it went to someone who didn’t have insurance before, someone who had their old policy cancelled or went to someone who voluntarily made the switch to a new one…which  . . is a LOT of people, by the way…is still a fully ACA-compliant, full-coverage healthcare plan.”

Gaba points out that “the primary point” of his website ( “is to track how many people are now enrolled in a “QHP certified” plan regardless of whether they had insurance before or not. Some moved from no plan at all to a QHP. Others moved from a ‘junk’ policy to a QHP (some have argued that there aren’t that many of these, but there were still a lot of them). Still others yet (myself included) have moved from a decent plan to a QHP. . . . The point is, they’re all ACA QHPs now.” [his emphasis]

This is critical to understanding the purpose of health care reform. From the beginning the goal of the Patient Protection and Affordable Care Act (PPACA) was not simply to insure the uninsured, but to protect the under-insured by making certain that everyone has comprehensive coverage.  Whether a carrier is peddling policies in a state marketplace or off-exchange all plans now must comply with the ACA’s rules by:

–covering the ten essential benefits

–offering free preventive care, and

–capping how much a patient can be asked to pay out-of-pocket.

In addition, carriers can no longer discriminate against customers suffering from pre-existing conditions by charging them exorbitant premiums, and they cannot set a limit on how much the insurer will pay out, over the course of a year or a lifetime.

The second goal of the Patient Protection and Affordable Care Act is to make sure that the price of such high quality insurance is not beyond reach. Government subsidies help low-income and median-income families, but the only way to make sure that everyone else can afford policies that meet the ACA’s high standards is by asking all of us to share in the cost.

This is why the ACA mandates that everyone purchase insurance. When more people pay into the risk pool, the costs decline for everyone. It is only then that universal coverage becomes possible



Obamacare Enrollment, Including Medicaid, Heads for 14-20 Million

Revised: April 12

Charles Gaba, who has become the go-to-guru for Obamacare enrollment numbers, now predicts that by April 15, 7.09 to 9.75 million Americans will have purchased health insurance in the Exchanges. 

This is in line with the back-of-the-envelope estimate that he offered a week ago: “a nice round 8 million.”  (In parentheses, he suggested:  Perhaps a little higher (1M even?)., and then struck that thought.  “As always,” he noted, “I’ll be more than happy to be proven wrong, as long as I’ve undershot the mark.”


To that 7.09 to 9.75 million, he now adds 2.09 million who he is certain have bought comprehensive coverage outside the Exchange, plus an additional 5.7 million who, according to a Rand study published earlier this week, may have signed up  off-Exchange. Finally, Gaba estimates that 5.23 million to 7.29 million Americans have enrolled in Medicaid or CHIP. 

As of April 12, this brings the total number who will have insurance that meets the Affordable Care Acts (ACA’s) high standards to roughly 14 million to 20.2 million.

When Gaba first reported on the Rand report, he acknowledged that Rand’s numbers “were based on a survey” and “surveys include margins of error.”

Gaba has gained his reputation by being meticulous—and cautious. Typically, his estimates have been conservative. Given that track record, I suspect that by April 15, we will find that well over 14 million people have benefited from Obamacare. If pressed, I would guess 17 million.

At this point, you may be wondering: But don’t we need the new enrollees who are purchasing policies off-Exchange to join the state marketplaces in order to spread the cost of coverage among as many people as possible?

The answer is “No.”

A little-known provision in the ACA stipulates that if a carrier sells policies to individuals both in the state marketplace and in the private market, the insurer must view those customers as part of one risk pool, and price their policies accordingly. Together, they will  share the risk of becoming sick, while also sharing the cost of insurance that guarantees everyone access to care. All other things being equal, the larger the pool of people who buy coverage both on and off the Exchanges, the lower the risk– and the lower the cost for all of them.

“All other things being equal” includes whether the new people jumping into that pool are healthy. Recent evidence suggests that the new entrants are, in fact, younger, and as a result, more robust than those who signed up earlier.

In future posts, I’ll take a closer look at that pool, and explore how much you are likely to wind up paying for insurance next year.