By Perry Bacon Jr.
Saturday, January 2, 2010; A02, Washington Post

Even as Democrats seek the biggest expansion of health coverage in decades, as many as 23 million people could still be without insurance by 2018, illustrating the complexity of achieving the long-held Democratic goal of universal health care.

The legislation that the Senate passed Christmas Eve, which is expected to resemble closely the final bill that is hashed out between the House and Senate over the next month, would leave about 8 percent of the population under age 65 without health insurance, according to the nonpartisan Congressional Budget Office. It would extend insurance to 31 million of an estimated 54 million who would have no coverage without the legislation.

"The impact of the reform overall is that we can focus more on care and less on how we pay for the uninsured, but the problem is still going to be there," said Chip Kahn, president of the Federation of American Hospitals, a lobbying group that has endorsed the Democratic plan.

But those who would be left uninsured have drawn little attention. This is in part because their ranks would include many who choose not to get health insurance, even though they can afford it -- such as some healthy people under 30, who have little effect on rising health-care costs because they rarely go to the doctor. Though starting in 2014, individuals would face fines if they do not buy coverage, some may still refuse.

About a third of the uninsured would be illegal immigrants. Neither party supports expanding insurance to cover them, even though states spend millions caring for them at hospitals, where emergency rooms accept patients regardless of coverage.

Some Republicans have seized on the uninsured number to attack the health-care legislation, even though they oppose mandating the purchase of insurance and covering illegal immigrants. "After raising billions in new taxes, cutting about a half-trillion dollars from Medicare, and imposing stiff new penalties for people who don't buy insurance and increasing costs for those that do, 23 million people will still not even have health insurance," Sen. Charles E. Grassley (R-Iowa) said before the Senate vote.

White House spokesman Reid Cherlin countered that "tens of millions of Americans will gain affordable coverage under this bill."

Despite complaints about those left uninsured, some health-care experts defend the legislation, noting the difficulty of reaching 100 percent coverage.

"If you're at 84 percent and you are going to 94 percent, you picked up roughly two-thirds of the problem, which is big," said John Holahan, director of the Health Policy Center at the liberal Urban Institute, referring to the percentage of legal U.S. residents who will have health insurance under the Senate plan. "If the economy comes back, you can pick up a good chunk of the rest. Most European countries don't get 100 percent -- the data I've seen is always 98 or 99 percent."

The CBO has not released a breakdown of who would make up the 23 million. Along with illegal immigrants and people who choose not to buy coverage, there are two groups of people likely to be uninsured: those who are eligible for Medicaid but don't sign up for it, and those who would qualify for an exemption from the coverage mandate because paying for insurance would take up more than 8 percent of their income.

The CBO estimates that the House version of the legislation would expand insurance to 36 million people, reducing the ranks of the uninsured to about 18 million. It would offer slightly higher subsidies for low-income people, reducing the number who cannot afford insurance, and it has stronger penalties for companies that do not offer insurance to workers and individuals who do not purchase it. But the House legislation would cost more than $1 trillion, compared with the $871 billion Senate package.

Latino activists and some Democratic lawmakers have complained about a provision in the Senate bill that bars illegal immigrants from purchasing insurance in new health insurance exchanges, which would serve people who do not have affordable employer-based coverage. Without access to those exchanges, such immigrants would have few health insurance options, although it's not clear how many could afford or would want to purchase coverage.

There is little support in Congress for extending health insurance through Medicaid or subsidies to the millions of illegal immigrants in the United States.

Congress is seeking to cover people who are under 30 and who find insurance an expense they can live without because they are generally healthy; many in this group hold part-time jobs that do not offer coverage. Lawmakers' goal is twofold: reducing the burden on hospitals to care for the uninsured and broadening the pool of people with insurance, since including those who are healthy helps lower costs for the ill. The legislation would create health plans with low monthly costs designed to appeal to young people.

Some experts say this group -- 13 million Americans, according to some estimates -- will remain sizable despite the mandate. But David Cutler, an economist at Harvard who advised Barack Obama on health care during the presidential campaign, said this group could be almost universally insured if the law was implemented properly, thereby reducing the total number of uninsured to much less than 20 million.

He said that if the bill becomes law, the government should look to Massachusetts, which passed a requirement in 2006 that every resident get insurance. The state ran commercials during the broadcast of Boston Red Sox baseball games encouraging people to sign up, helping reach young men. Only about 45,000 of the nearly 4 million who filed taxes last year in Massachusetts were fined for refusing to buy insurance.

Cutler said a similar effort could encourage people who would newly qualify for Medicaid, which would be expanded to cover most households earning less than $30,000 a year.

"If we do it right," Cutler said, "I'm not very worried we will have lots of uninsured."

Research editor Alice Crites contributed to this report.