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Obamacare leaves millions uninsured. Here’s who they are.

Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, and read previous columns here.

When we talk about the Affordable Care Act, we mostly focus on the millions of Americans who will gain health insurance coverage. We talk less about the millions who will remain uninsured.

And there are a lot of them: 30 million Americans will not have coverage under Obamacare, according to a new analysis in the journal Health Affairs. 

"Even if the law were fully implemented, there would have been 26 million uninsured people," co-author Steffie Woolhandler said in an interview Thursday. "This isn't just about the Medicaid expansion. This is the system as originally designed."

Thirty million is a lot smaller than the 48.6 million Americans who lack insurance coverage right now. It's also, as Woolhandler points out, not exactly breaking news: The Congressional Budget Office estimated over a year ago that between 26 million and 27 million Americans would not have insurance under the expansion.

Woolhandler and her colleagues have done one of the most in-depth analyses of the uninsured under Obamacare that I've seen. They look at who will be uninsured in 2016, a few years after the health law's insurance expansion takes place. You can expect these numbers to change (likely to shrink) in later years, as budget forecasters expect enrollment in health law programs to grow gradually.

One of the most surprising findings, perhaps, is that the vast majority of the uninsured under Obamacare -- 80 percent -- will be U.S. citizens. This is true in the two scenarios that the researchers looked at, one in which states on the fence about the Medicaid expansion opt-in and one in which those states opt out. As you can see, there's not much of a difference.

Uninsured under Obamacare by nativity status (millions)

The uninsured under Obamacare tend to be between between ages 18 and 44, with a few million in younger and older age demographics.

This analysis suggests that the uninsured under Obamacare will be heavily low-income, even though many of those people will have access to subsidized health insurance. Still, some might not find it affordable, and the health care law does allow for an exemption from the individual mandate for those who cannot find affordable coverage (defined as insurance that costs less than 9.5 percent of an individual's income).

"If people are not eligible for Medicaid, then affordability can be a big deal," Woolhandler says. "Even with subsidies, you could see some people who either can't find affordable coverage or decide to pay the mandate."

The researchers also broke it down by employment status, which shows that most of the uninsured will be employed:

And, last but not least, here is the breakdown by race:

Kliff Notes: Top health policy reads from around the Web.

Consultants expect glitches in the exchanges' launch. "Unlike travel websites, for instance, where consumers can simply compare prices and purchase airline tickets, the health-insurance websites face a far more daunting task. Behind the scenes, computer programs must communicate with the Internal Revenue Service and other U.S. government databases to confirm that the applicant is a U.S. citizen or legal resident and, if so, whether the person is eligible for subsidies to get coverage." Jennifer Corbett Dooren in the Wall Street Journal

Obamacare outreach will focus heavily on young people and Latinos. "Of the 6 million people in California who are expected to shop for insurance in the state’s exchange, at least 1.3 million are Spanish speakers and are eligible for a subsidy to help pay for health insurance. California, according to the White House, is already emerging as the model for a successful outreach campaign." Jenny Gold in Kaiser Health News.

Michigan's Republican governor is urging state legislators to expand Medicaid. "Gov. Rick Snyder is redoubling his efforts to get lawmakers this month to approve expanding the Medicaid health insurance program for the poor before the Legislature recesses for the summer. Snyder said Friday he has invited U.S. Health and Human Services Secretary Kathleen Sebelius to meet with Republican lawmakers to consider a House GOP proposal to put a four-year lifetime cap for able-bodied adults to be on Medicaid." Chad Livengood in the Detroit News.



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